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 polysomnography for evaluation of the enrollees obstructive sleep apnea.Findings:  The physician reviewer found that The physician reviewer found that this patient has documented obstructive sleep apnea that has been well-treated since 2011 with to bilevel positive airway pressure (BiPAP).  Recent records noted that the patients hypertension and diabetes were well-treated. On the date the polysomnogram was ordered, there was no documentation of daytime hypersomnia, driving accidents, poorly controlled hypertension, poorly controlled diabetes, or any difficulty with using BiPAP. The office note did not indicate why another polysomnogram was ordered. Any slight adjustments in BiPAP can be done with the use of the smart card compliance data that can document the apnea hypopnea index during sleep. Based on the documentation provided for review, the requested polysomnography is not medically necessary for the evaluation of 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 reviewer is board certified in internal medicine with sub-specialty certification in pulmonary 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: Experimental/Investigational
Decision: Upheld

A 46-year-old female enrollee has requested for sclerotherapy for treatment of her varicose veins.   Findings:  Three physician reviewers found that Ultrasound-guided foam sclerotherapy is investigational. This procedure is not more beneficial than available standard therapy. The current literature does not support the efficacy of this treatment over other available standard therapies.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old male enrollee has requested a FIBROSpect II study for an evaluation of his liver disease. Findings:  Two physician reviewers found that to date, it has not been shown that FIBROSpect II testing is as helpful or accurate as the gold standard in this setting, liver biopsy. No evidence has been presented that the proposed testing will have superior value in the care and management of this patients chronic Hepatitis C. In sum, it has not been established that FIBROSpect II testing will result in a better outcome for this patient than liver biopsy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections to be administered every 10 weeks.The International Headache Societys International Classification of Headache Disorders (ICHD) defines chronic migraine as headache occurring on greater than 15 days per month for greater than three months, which is not attributable to another disorder, and which has at least two characteristics of unilateral, pulsatile, moderate to severe in intensity, or aggravation by or causing avoidance of routine physical activity. Additionally, ICHD diagnostic criteria require that there must be one characteristic of nausea and/or vomiting, photophobia and phonophobia. Botox is a tool in the management of chronic migraine which has shown effectiveness in the PREEMPT trials. The PREEMPT 1 trial showed that significant reductions from baseline were observed for onabotulinumtoxinA (Botox) for headache and migraine days, cumulative hours of headache on headache days, and frequency of moderate/severe headache days, which in turn reduced the burden of illness in adults with disabling chronic migraine. The results of the PREEMPT 2 demonstrated that onabotulinumtoxinA was effective for prophylaxis of headache in adults with chronic migraine, and that repeated onabotulinumtoxinA treatments were safe and well tolerated. Both of these trials were designed, however, with twelve-week intervals between Botox administration. As of a result of these studies, Botox was approved by the Food and Drug Administration (FDA) for use in prophylactic management in chronic migraine. Therefore, the strongest evidence of Botox use is at the 12-week interval at which the trials were performed that supported FDA approval. Evidence supporting the use of Botox at alternative doses and frequencies is limited at best. Accordingly, the requested Botox injections to be administered every 10 weeks is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology, with subspecialty certification in vascular 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

The patient has requested authorization and coverage for Gammagard infusions, 21 grams every four (4) weeks. Based on the available documentation, there is a lack of laboratory data to support immunoglobulin replacement therapy for treatment of this patient. The records include documentation of mildly decreased total IgG levels in the setting of dermatologic and pulmonary infections. However, there is a lack of work-up to determine the patients antibody function or IgA and IgM levels. A diagnosis of common variable immunodeficiency requires reports of low IgG levels in addition to either low levels of IgA or IgM, and poor response to vaccines such as Pneumovax, diphtheria, and tetanus. Therefore, the requested Gammagard infusions, 21 grams every four (4) weeks, are not medically necessary for 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 internal medicine with subspecialty certification in allergy and immunology 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 is a 44-year-old female with constipation predominant irritable bowel syndrome (IBS). She has responded to Zelnorm therapy and is seeking continued authorization for Zelnorm. The Health Plan has denied this request. As part of its denial the Health Plan has referred to the patient not meeting Rome II criteria.IBS is a clinical diagnosis based on subjective symptom assessment. The patient has altered bowel habits with abdominal discomfort  the hallmark of IBS and its diagnosis. The patient has responded to and benefited from Zelnorm therapy. The Rome II criteria were developed for and are used in research studies to ensure a uniform patient population is enrolled in a study. The Rome II criteria have not been recommended for everyday clinical practice or shown to be applicable/effective in everyday clinical practice. As such, they are not applicable or relevant to this case.The patient has received effective, beneficial therapy with Zelnorm. There is no evidence such therapy should be discontinued. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 21-year-old male enrollee has requested inpatient brain-injury rehabilitation for the treatment of his traumatic brain injury. Findings:  Two physician reviewers found that although the head injury may have exacerbated the patients behavioral issues, it appears a thorough psychiatric evaluation would have been appropriate in this case, given the behaviors described by his mother. It is highly unlikely that the patients progression of symptoms several months after the trauma was attributable to the TBI.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested home nursing services for treatment of her medical condition. Findings:  The physician reviewer found that upon review of the record, home health services to administer the medication are not medically necessary because the documentation submitted does not demonstrate that the patient is homebound. Although the subcutaneous infusion of immunoglobulin is medically necessary for the treatment of the patient's condition, the patients record demonstrates that she is able to receive infusion at an outpatient medical facility. According to the medical literature cited, common variable immunodeficiency (CVID) includes individuals with varying degrees of loss of antibody. For those with substantial impairments in antibody production and nonresponse to protein and carbohydrate vaccines, immune globulin (IG) replacement is necessary. The use of immunoglobulin replacement has been shown to reduce both hospital admissions and antibiotic use in patient's suffering with this condition.  In this case, the patient is not homebound and therefore the use of home health services in treatment of the patients medical condition is not medically necessary. 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: Medical Necessity
Decision: Overturned

A 25-year-old female enrollee requested partial hospitalization program (PHP) level of care for treatment of her behavioral health condition.  Findings:  The physician reviewer found that, according to the medical records submitted for review, the patient meets the American Psychiatric Association (APA) guideline criteria for treatment at the PHP level of care. In this case, the patient is medically stable, has weight above 80%, has partial motivation, is cooperative but preoccupied with intrusive, repetitive thoughts at least three hours each day, needs some structure for her eating program and has some limited support and structure outside the program. Moreover, the patients complex psychiatric history and diagnosis of post-traumatic stress disorder may have indicated a higher level of care. Therefore, based upon the documentation submitted for review, the services at issue were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old male enrollee has requested a motorized wheelchair (power-operated vehicle) for treatment of his idiopathic transverse myelitis, suspected multiple sclerosis.  Findings:  The physician reviewer found that the submitted documentation does not substantiate the presence of impairments that would preclude the patient from accomplishing his mobility-related activities of daily living within the home with the aid of a manual wheelchair.  The records do not document any neurological or musculoskeletal impairment or pathology affecting the upper limbs.  He does not have a documented cardiovascular or pulmonary condition that is severe enough to preclude the use of a manual wheelchair to accomplish his mobility-related activities of daily living.  The power mobility device form signed by the patients primary care physician on the said date specifically endorses that the patient has sufficient upper limb function to propel an optimally configured manual wheelchair in the home through the course of a typical day.  With respect to falls, there is no evidence in the present case that would support that there would be a significant additional risk of falling when comparing a manual versus a power wheelchair.  All told, the requested motorized wheelchair (power-operated vehicle) is not medically necessary this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 53-year-old man who was found to have a PSA of 3.0 on 1/14/04. A palpable nodule of 8mm was noted at the right apex of the prostate. Three biopsy specimens from the right apical prostate nodule revealed a Gleason score of 3+4 in one-third of the core. In March 2004, the patients provider recommended standard radiation therapy or radical prostatectomy. The patient was seen in consultation by another provider for consideration of proton beam therapy. It was recommended the patient receive daily treatments for eight weeks. The patient wishes to undergo proton beam therapy rather than conventional radiation therapy. The Health Plan has denied authorization and coverage for proton beam therapy on the basis that it is not medically necessary.The patient is a 53-year-old man with a PSA of 3.0, T2a, and Gleason score of 3+4=7. Based on Partins Tables, there is a 50% chance the cancer is confined to the prostate, a 41% chance of capsular involvement, a 7% chance of seminal vesicle involvement, and a 2% chance of pelvic lymph node involvement. In light of this, the patient is not a good candidate for a localized therapy. The patient is likely to experience the most benefit from neoadjuvant hormone therapy for three months followed by a reevaluation with PSA and DRE. If the patient has a good response to neoadjuvant hormone therapy, he could then be treated with conventional radiation therapy. If the patient has no response to neoadjuvant hormone therapy, proton beam therapy may be an acceptable alternative. At this time, proton beam therapy is not medically indicated.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for an ultrasound of kidneys (CPT-76770).Renal medullary carcinoma is a rare kidney cancer that affects adolescents and young adults. Renal medullary carcinoma occurs almost exclusively in people with sickle cell trait. The most common presenting symptoms include gross hematuria, flank pain, and abdominal masses, with males disproportionately affected. Renal medullary carcinoma is characterized by early and widespread metastatic disease and resultant poor prognosis. One hallmark of the tumor itself is the loss of SMARCB1/INI1, a feature shared with a number of childhood cancers. Treatment generally involves nephrectomy and systemic chemotherapy. Clinical trials remain the mainstay of treatment for this disease. Authors noted, No evidence points to the benefit of screening individuals with sickle cell trait for renal medullary carcinoma because currently, no feasible schedule and modality of screening would have a likelihood of identifying the presentation of disease at an early stage. In addition, no effective measures exist for the prevention of renal medullary carcinoma. Per researchers, ultrasound imaging is insufficient for the diagnosis of renal medullary carcinoma or medullary renal lesions. Therefore, the requested ultrasound of kidneys (CPT-76770) is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in pediatrics, with subspecialty certification in pediatric critical care 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: Upheld

A 53-year-old female enrollee has requested laser treatment for the treatment of her redness and scarring secondary to a reaction to Efudex. Findings:  The physician reviewer found that the submitted documentation does not demonstrate the presence of an abnormal structure of the body caused by infection, trauma, tumor or disease. Wrinkles or rhytids, pigmentation changes, keratoses, and telangiectasias are among the clinical signs of photodamage that is part of the normal aging process. Upon viewing the submitted color reproductions of the photographs, there is visible mottled pigmentation but no visible scarring or abnormal structures. The mottling is not severe enough so as to be considered out of the norm for an aging individual. Thus, the proposed therapy does not meet the requirements of Californias Reconstructive Surgery Statute. With regard to the medical necessity of the proposed therapy, the submitted documentation does not demonstrate the presence of a functional deficit that is likely to be resolved by laser therapy. There is no evidence of complaints of infection, pain or deterioration of the skin. While the patient has concerns over the appearance and texture of her skin, these issues are cosmetic in nature and do not constitute a functional impairment. As such, the proposed laser therapy is not necessary from a medical standpoint.
Appeal type: Medical Necessity
Decision: Overturned

A 32-year-old female enrollee requested authorization and coverage of a referral to an orthopedist for treatment of knee dislocation.  The health plan denied the enrollees request indicating that the requested referral is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested referral is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested intensive outpatient program services and continued intensive outpatient program at a frequency of four times per week for treatment of her bulimia nervosa.  Findings:  The physician reviewer found that the data reviewed indicate that the patient shows good motivation and has no history of suicidal behavior despite the presence of some passive suicidal ideation. Her weight has increased, and there is no indication of laboratory abnormalities, deranged vital signs or other evidence of physiological compromise. There is no risk to others, and no indication that she presents a potential risk to be placed in a higher level of care if she is not in this program. The information submitted for review in sum fails to establish the medical necessity for this level of care. It is not evident that she has benefitted substantially, and there is no indication of medical compromise. Per the submitted documentation, the medical necessity of intensive outpatient program treatment provided from the said date onward has not been established.  Additionally, continued outpatient treatment of any frequency is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment care for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. To objectively determine if the patient meets criteria for length of stay, the Level of Care Utilization System (LOCUS) criteria was used. This is an accepted, national standard for determining the appropriate level of care for adults.  In terms of risk of harm, the patient scored a 3. The patient had a moderate risk of harm. He had no history of suicidal ideation or suicide attempts. He was consuming two to four bottles of wine per day and had driven under the influence. The patient was admitted due this increased risk and detoxified. The patient was motivated for treatment and was participating in groups and other treatment. In terms of functional status, the records support a score of 3. The patient demonstrated moderate impairment.  He was employed, although his drinking disturbed his ability to fulfill his responsibilities and obligations. With regards to medical/addictive/psychiatric comorbidity, the records support a score of 3.  The patient had a significant comorbidity of alcohol use disorder, attention deficit/hyperactivity disorder, sedative hypnotic use disorder, stimulant use disorder, depression and generalized anxiety disorder. The patient continued to use substances despite negative consequences.  In terms of recovery environment, the patient scored a 2.  The records indicate a mildly stressful environment. The patient lived with his parents. Per documentation, it is a sober environment. With regards to the level of support, the records support a score of 2. The patient had a supportive environment. His parents were supportive. With records to treatment history, the records support a score of 2. The patient has had prior treatment and was sober for 13 years.  In terms of engagement and recovery status, the records support a score of 2.  The patient was motivated for recovery and was compliant with treatment recommendations.  Thus, the records support a total score of 17. Based on these criteria, the patient would meet criteria for an intensive outpatient program. Therefore, residential treatment care provided was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue 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: Upheld

The parent of a nine-year-old male enrollee has requested for a second cochlear implant (bilateral) for treatment of the enrollees bilateral sensorineural hearing loss. Findings:  The physician reviewer found that while current literature suggests that there may be an additional benefit to binaural amplification for some patients, many of the studies involved small numbers of subjects and lacked controls for comparison. Many patients derive significant benefit from unilateral hearing amplification. In this instance, the patient is reported to be performing well in testing, socially and at school, with the single cochlear implant. A second Cochlear implant for any patient involves a small, but real, surgical risk. Rare complications of Cochlear implants include meningitis and other risks implied in a delicate surgical procedure in this area. The current evidence on the benefit of binaural implants is inadequate, and no implant has been approved by the FDA for binaural use. Should the current implant on the left side fail, the patient would require a replacement implant for the right ear.