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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential psychiatric level of care services provided from date of dispute and forward. Findings:  The physician reviewer found that the medical evidence and the documentation provided do not support the medical necessity of the services at issue in this clinical setting. Outpatient treatment and least restrictive options are considered first lines of care as referenced by The American Academy of Child and Adolescent Psychiatry. The standard of care for treatment of children and adolescents should be in the least restrictive setting as possible in order to maintain and foster natural supports. It is further recommended that children should be treated in the setting that is least restrictive and disruptive to their lives. Inpatient or residential treatment is indicated only in emergencies or for children who have not responded to efforts at outpatient treatment. In a study children in intensive in-home therapy were more likely to live with family, make progress in school, not have trouble with the law, and have better placement permanence than youth who were treated in residential treatment facilities. The progress notes indicate that by the date of dispute, the patient was cooperative with her treatment plan. She was noted to be providing and accepting good feedback while in group therapy. She did not display dangerous behaviors. There were no documentation as to aggressive behaviors towards peers or staff during her stay. The records do not indicate that the patient had any symptoms that would have necessitated continued residential care. The documentation indicates that the patient was acquiring coping skills and was not having any attempts to harm herself.  Her family was also involved actively in her treatment.  Her treatment goals could be accomplished on an outpatient basis. She was receiving DBT and this was recommended on discharge. All told, residential psychiatric level of care services provided from date of dispute forward were not and are not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the services at issue were not and 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 sub-specialty certification in child and adolescent 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested capsule endoscopy for evaluation of her medical condition. Findings: The reviewer found that in this case, capsule endoscopy is medically necessary to evaluate abdominal pain in this patient with prior cancers and history of possible mass on imaging. This was not seen on subsequent imaging. The complete small intestine cannot be examined during endoscopy or enteroscopy. Capsule endoscopy is more sensitive for small intestine mass than imaging (which was negative). According to the Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy, evaluation for suspected small intestinal tumors, which this patient has had in the past, is a valid indication for capsule endoscopy. Capsule endoscopy is capable of discovering small bowel tumors missed by endoscopy and traditional radiologic imaging. Computed tomography (CT) enterography has 84.7% sensitivity for the detection of small bowel tumors, meaning that over 15% of tumors are missed. Magnetic resonance enterography misses a similar number of tumors.  Capsule endoscopy is reported as having high sensitivity in identifying small-bowel tumors. One comparison of these modalities for evaluation of small bowel tumors reported that the techniques complement each other, providing information that the other cannot. Based on the literature, further evaluation is needed, and capsule endoscopy (a high-sensitivity modality for this) is medically necessary in this clinical setting.Final Result: The reviewer determined that the requested services are 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 24 hours or more of licensed vocational nurse (LVN) services a week and one hour per month of registered nurse (RN) supervision for treatment of the enrollees achondroplasia, autism, left eye blindness, single kidney, developmental delay, and feeding problem with gastrostomy tube. Findings:  The physician reviewer found that that this patient has been stable without any complications of chronic medical conditions. Further, the patient does not require a skilled nurse for care of a feeding tube. Care for a gastrostomy tube can be taught to a non-medical person for administration of medications and nutrition. Overall, the patinet's needs are custodial in nature and do not require the services of a skilled nurse. 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Daklinza for treatment of his hepatitis C virus. Findings:  The physician reviewer found that pursuant to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. In this case, the patient is ineligible for ribavirin due to a pre-existing condition that proved to be exacerbated in a placebo-controlled trial of ribavirin monotherapy. AASLD/IDSA guidelines only recommend one regimen for treatment-naive ribavirin-ineligible genotype 2 patients: Daklinza and Sovaldi. The guidelines state that consideration of extending treatment to 24 weeks for patients with poor baseline characteristics is reasonable. This recommendation is based on two clinical trials. For these reasons, the requested Daklinza is supported as medically necessary for treatment of this patients hepatitis C infection. 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 fifty-eight year-old male who has degenerative disc disease and pain is requesting reimbursement and prospective authorization for physical therapy.Reviewers Findings:The reviewing physician found that based on the available records, further physical therapy was not medically necessary.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for: 1) advanced lipoprotein testing services; 2) advanced lipoprotein testing services; 3) advanced lipoprotein testing services; 4) advanced lipoprotein testing services; 5) advanced lipoprotein testing services; and 6) the blood genetic testing services. Based on the records provided, this patient has known obstructive coronary disease. In this circumstance, guidelines for the management and dyslipidemia and coronary disease have been established, are periodically updated by expert committees, and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low density lipoprotein (LDL), high density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, homocysteine, and genetic testing. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. In addition, this patient has known obstructive coronary disease, which warrants aggressive risk factor reduction with high dose statin therapy regardless of lipoprotein test results. Given these findings, the 1) advanced lipoprotein testing services; 2) advanced lipoprotein testing services; 3) advanced lipoprotein testing services; 4) advanced lipoprotein testing services; 5) advanced lipoprotein testing services; and 6) the blood genetic testing services, were not likely to have been more beneficial for evaluation of this patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certifications in cardiovascular disease and interventional cardiology and is 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 reimbursement for air and associated ground ambulance transportation services the patient received from Angel MedFlight.There is a lack of support for the services at issue in this clinical setting. Air medical transport is medically necessary when specific criteria are met. These criteria include: the patients condition must be such any form of transportation other than ambulance would be medically contraindicated; the patients condition is such that time needed to transport by ground poses a threat to survival; the individual is transported to the nearest hospital with appropriate facilities for treatment; and there is a medical condition that is life-threatening. When transporting from one facility to another, the above criteria must be met, and the first hospital must not have the required services and facilities to treat the patient. In this case, the patient was not being transported to another facility. He had been discharged from the hospital and was transported by air and ground ambulance to his home. Therefore, none of the air or ground ambulance transport criteria are met. Under these circumstances, air and associated ground ambulance transportation services the patient received from Angel MedFlight were not medically necessary for the treatment of the patients medical condition.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 emergency 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 authorization and coverage for acupuncture services. The submitted documentation supports the medical necessity of the requested services in this clinical setting. The records document a history of right shoulder pain. The patient has participated in physical therapy, but remains symptomatic. The clinical notes document loss of function. In this setting, an initial trial of acupuncture is medically appropriate. Given that the patient continues to be symptomatic despite prior treatment modalities, the requested acupuncture services are indicated for pain management and function improvement. Therefore, the requested acupuncture 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 licensed acupuncturist, board certified in oriental 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

The enrollee is requesting reimbursement for Orthovisc injections for the right knee. The enrollee has pain in the right knee. He has a chondral defect of the lateral femoral condyle in the right knee. He continued to experience pain, swelling, stiffness, popping, catching, instability, and weakness. The orthopedic surgeon advised treatment with viscosupplementation and ordered Orthovisc injections for the enrollee, along with continued use of his custom knee brace. According to a professional society, the use of intra-articular hyaluronic acid injections is indicated for the treatment of osteoarthritis in the knee in adults who do not respond to other treatment options. Records show the enrollee demonstrated symptom improvement with previous hyaluronic acid injections. The magnetic resonance imaging scan shows arthritic change and degeneration of the joint. Based on the positive response to hyaluronic acid injections and the literature support for hyaluronic acid injections for osteoarthritis, literature supports the hyaluronic acid injection to the knee is clinically appropriate and medically necessary to treat this enrollee's medical condition.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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance angiography (MRA).Findings:  The physician reviewer found that the available documentation, this patient underwent evaluation with contrast-enhanced computed tomography (CT) of the chest, which showed normal pulmonary parenchyma and thoracic vascular anatomy. A coronary CT angiography demonstrated normal coronary anatomy and confirmed that the patients mediastinal mass was stable at the four-month interval. Based on current medical literature, the requested MRA is not expected to provide further advantage to visualizing the patients thoracic anatomy or anterior mediastinal mass beyond the studies already performed. Moreover, in common differential diagnoses of vestibular migraine, audiologic testing and magnetic resonance imaging (MRI) have greater initial clinical utility than vascular imaging (Ackman, et al.). Given that a CT of the chest and CT angiography have been performed to evaluate this patient for vascular pathology, MRA of the same region is not consistent with current medical literature recommendations. For these reasons, the requested MRA is not medically necessary for 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 subspecialty certifications in pulmonary disease and 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for services at Regional Medical Center of San Jose. The patient presented to the emergency department with two days of pain not controlled with pain medications and was anxious and in mild distress due to pain. Halawi and Morwood report that open fractures are complex injuries associated with high morbidity and mortality, establishing the need for emergent treatment of an open fracture. Kloen and colleagues note that temporary joint-spanning external fixation before internal fixation of open intra-articular distal humeral fractures is a safe adjunct, and the patients external fixation followed this typical protocol. Kosters and colleagues report that the surgical treatment of comminuted fractures of the distal humerus remains a challenging problem. In this case, the location of the patients fracture is relatively unique in orthopedics as the elbow is significantly prone to stiffness and the emergent treatment left her with an immobilized elbow, which has been shown to yield significant elbow stiffness. In this patients case, the absence of immediate medical attention could be reasonably expected to result in serious dysfunction of a body part. Therefore, the services provided at Regional Medical Center of San Jose were emergency services. Final Result: The reviewer determined that the services at issue were emergency services. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old female enrollee has requested bilateral axillary hair removal sessions for treatment of her hyperhidrosis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. Per the medical records, her condition is currently well-controlled with Botox injections.  Treatment of axillary hyperhidrosis is often effective with topical therapies, oral therapy, or Botox injections.  There is a lack of support for the requested services in this clinical setting.  All told, the requested bilateral axillary hair removal sessions are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 31-year-old male with alcohol and cocaine dependence is requesting coverage for residential treatment.Reviewers Findings:  The reviewing physician found that the medical records provided shows that the patient did not meet accepted criteria for admission to the residential level of care for adult substance abuse. There are no notes in the chart that indicate that the patient was attended to by a physician during this stay.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old male enrollee has requested morphine for treatment of his chronic pain.  Findings:  The physician reviewer found the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce that pain. Opiates are considered adjunctive to this therapy; in cases in which they are necessary, the use of controlled release narcotics with close monitoring by a certified pain management specialist is highly recommended (Fishman). Baron and McDonald reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a pre-existing pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia (Baron and McDonald). Finally, high dose opiates may also cause adverse outcomes. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. In this clinical setting, opioids for the patients chronic pain would be contradictory to providing safe and effective medical treatment. Therefore, the requested medication is not medically necessary for the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old male enrollee requested authorization and coverage of a referral to a neurologist for treatment of arm pain. 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.