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

A 50-year-old female enrollee requested evaluation at a medical transplantation center for medical treatment of the enrollees end-stage renal disease.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  Per the medical evidence, there is a survival superiority of kidney transplant compared to dialysis.  The records indicate a significantly shortened waiting time for kidney transplant at one transplantation center location versus another.  Patients such as this patient with diabetes mellitus have a shorter life expectancy on dialysis.  In this patients case, a longer waiting time for kidney transplantation is associated with significant risk.   Since this patient has already been listed as a transplant candidate at one transplantation center, it is likely that she could be listed at another transplantation center.  Additionally, she could transfer her waiting time from the first transplantation center to the second transplantation center, and delete her first listing, so she would only continue to be listed at a single center.
Appeal type: Experimental/Investigational
Decision: Upheld

A 30-year-old female enrollee has requested percutaneous tibial nerve stimulation (PTNS) for the treatment of her interstitial cystitis. Findings:  Three physician reviewers found that PTNS is not likely to result in a lasting improvement as this therapy is entirely experimental and investigational. It has not been proven unequivocally to result in superior outcome over conventional therapy. There are no evidence-based studies which show superiority.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 46-year-old male with an extended history of eye irritation and redness.  He was initially evaluated by his optometrist, and then referred to an ophthalmologist within his Health Plan.  A diagnosis of episcleritis was made in 2004. The patient indicates that his condition did not resolve after two years of treatment, and he self-referred for homeopathic treatment. The patients request for reimbursement and continued authorization for homeopathic care and medication was denied by the Health Plan citing a lack of medical necessity.Chronic irritation and itchy eyes are very common conditions. In this case, the evidence of episcleritis is not overwhelming. It appears there is an inflammatory condition that is recurrent and often subsides with or without treatment. The clinical description of the patients condition is of a chronic condition that ebbs and flows. If treated during a period of remission, the treatment seems very effective. If treated during a period of exacerbation, the treatment does not give the impression of efficacy. There are no miraculous cures, and effective treatment generally involves on-going symptom management. I would question the use of steroids. With regard to the homeopathic medications, there is no scientific database to provide objective support of their efficacy. The homeopathic practitioner indicated in his notes that the eye drops were for allergy eyes. These drops would likely serve the purpose of washing out the offending agents and soothing the irritation, similar to the treatment the enrollee received within the Health Plan.Based upon the information set forth above, I have determined the services at issue were/are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 24-year-old male enrollee requested authorization and coverage of Aredia infusions. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees osteoporosis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for neratinib (Nerlynx). Findings:  The physician reviewer found that currently, Nerlynx is indicated for the extended adjuvant treatment of early stage HER2-positive breast cancer, after completion of adjuvant trastuzumab based therapy. Per the U.S. Food and Drug Administration (FDA) approval, Nerlynx is also used for extended adjuvant therapy after Herceptin based therapy in early breast cancer. However, Nerlynx is not approved for metastatic disease. Moreover, there is a lack of peer-reviewed medical literature reporting improved health outcomes in patients with use of Nerlynx in this clinical setting. For these reasons, the requested Nerlynx is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the requested medication is 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: Physician reviewers 1,2 & 3 are  certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for surgical consultation and/or bilateral breast implant removal with en bloc capsulectomy. Authors noted that, autoimmune/inflammatory syndrome by adjuvants (ASIA), allergies, autoimmune diseases, immune deficiencies and lymphomas occur in patients with silicone breast implants. Researchers also reported that, the evidence remains inconclusive about any association between silicone gel implants and long-term health outcomes. Overall, ASIA is not a confirmed disease entity. Moreover, ASIA is not associated with saline breast implants. This patient presents with bilateral breast pain. She has with subpectoral saline implants. A mammogram showed a small nodular density in the inferior left breast, and the provider recommended further examination. There is no report of any abnormal physical findings related to the breast implants. Further, there are no constitutional symptoms consistent with breast implant illness documented in the records provided for review. All told, the requested surgical consultation and bilateral breast implant removal with en bloc capsulectomy are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested Botox injections for the treatment of her migraine headaches. Findings:  The physician reviewer found that this patient received Botox in a pattern and documentation consistent with cosmetic treatment. The patients only submitted records are from her dermatologist whose extensive billing records only document treatment of dermatologic conditions. There are no records or diagnostic codes concerning diagnosis or treatment of migraines.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 10-year-old male enrollee has requested 10 hours per week of direct applied behavioral analysis (ABA) treatment (H2019); and 6 hours per month of supervised and/or parent training (H0032); and 1.5 hours per week of social skills group/skills development group (H2014) for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that ABA literature demonstrates that major improvements are generally recorded after 2 years of intensive ABA therapy (Remington et al), and as noted above, this patient showed a moderate degree of improvement with earlier treatment. More recently, the patients progress has been limited. While continued ABA therapy is medically necessary for this patient, the requested frequency of therapy is excessive in this clinical setting. The medical literature supports the reduction of ABA hours to be replaced by school attendance and group social activities as the child ages. A study by Reichow and Volkmar indicates that ABA therapy directed toward specific maladaptive behaviors may be effective in the older child. In this patients case, he requires additional therapy to address vocal and physical self-stimulatory activities. Therefore, 5 hours per week of direct applied behavioral analysis (ABA) treatment, 1 hour per month of supervised and/or parent training and 1.5 hours per week of social skills group/skills development group are medically appropriate and necessary for treatment of the patients medical condition. Based on the medical literature cited above and the documentation submitted for review, a portion of the services at issue were and are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 31-year-old female with a BMI of 45. She has comorbid conditions including hypercholesterolemia and elevated blood pressure. She wishes to undergo gastric bypass. She has not undergone a formal psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery.With a BMI of 45 and comorbid conditions, the patient meets accepted national medical necessity criteria for consideration of weight loss surgery. Roux-en-Y gastric bypass is medically indicated and medically necessary for treatment of this patients morbid obesity. Furthermore, scientific evidence does not show that structured weight management plans consisting of diet and exercise have been successful in the treatment of the morbidly obese. The study referenced above demonstrates that surgery has the best long-term outcome for the morbidly obese. However, although medically the patient meets criteria for consideration of weight loss surgery, there is no evidence that the patient has undergone a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery. Such an evaluation is considered standard of care prior to authorizing weight loss surgery.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. Therefore, the Health Plans denial should be overturned. If the psychological evaluation indicates the patient is an appropriate candidate for weight loss surgery, the procedure should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery the procedure should not be authorized.
Appeal type: Medical Necessity
Decision: Overturned

The father of a 16-year-old female enrollee requested authorization and coverage of residential treatment services. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees behavioral health problems.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer partially overturned the Health Plans denial on the basis that the requested services were medically necessary through 9/30/03.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for an increase from #30 per month of carisoprodol (Soma) 350 mg to #60 per month of carisoprodol (Soma) 350 mg for treatment of the enrollees pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantity. The recommended maximum duration of use of carisoprodol is up to two to three weeks. This medication is indicated for relief of discomfort associated with acute, painful, musculoskeletal conditions. It is not appropriate for chronic use. In this patients case, the risk of side effects outweighs the potential benefits of this treatment. The current medical evidence does not support the requested medication quantity in this clinical setting. All told, the requested increase from #30 per month of carisoprodol (Soma) 350 mg to #60 per month of carisoprodol (Soma) 350 mg is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication quantity 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 anesthesiology with sub-specialty 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a gait trainer. The records indicate that the patient has significant to profound cognitive and physical impairments. She is unable to follow commands; has visual impairment and limited limb mobility, with contractures. There is no documentation in the available records of a completed, pertinent, recent physical examination or functional mobility evaluation; establishing that the patient is able to safely and effectively use a gait trainer even for therapeutic ambulation for exercise, let alone purposeful mobility. In any case, it is not being used for functional mobility. The gait trainer in question is also not necessary for a medical purpose, as there is insufficient evidence to establish that this type of device improves health outcomes. Therefore, the gait trainer is not medically necessary for the patients condition.Final Result: The reviewer determined that the requested device 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 physical medicine and rehabilitation 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 Sovaldi and Daklinza for treatment of his hepatitis C.   Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions.  In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 12 weeks.  For these reasons, the requested treatment with Sovaldi and Daklinza is medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications 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 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 34-year-old male enrollee has requested for Lap Band surgery for treatment of his obesity.  Findings:  The physician reviewer found that the guidelines set forth by the National Institutes of Health indicate that a patient may be a candidate for surgery if they have a BMI of 40 or more, or a BMI between 35 and 39.9 and a serious obesity-related health problem such as type 2 diabetes, coronary heart disease, or severe sleep apnea. This patient does not have a BMI of 40 or greater and does not have any of the significant co-morbid conditions indicated by the National Institutes of Health in the guidelines for Bariatric Surgery for Severe Obesity.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging to determine if there is sciatic nerve damage for evaluation of his history of lower back pain. Findings:  The physician reviewer found that the medical literature supports obtaining an imaging study when it will change the course of therapy.  The correlation between magnetic resonance findings and clinical symptoms requires strict clinical correlation. The American College of Radiology (ACR) has established appropriateness criteria to evaluate various clinical presentations, including low back pain.  The guidelines indicate that imaging patients with acute low back pain (LBP), of less than six weeks duration and no red-flag symptoms provide no clinical benefit (ACR Appropriateness Criteria). In another publication, the ACR states, Interestingly, the size and type of disc herniation and location and presence of nerve root compression were not related to patient outcome. A recent study found no statistically significant difference in primary outcome after 1 year for older adults who had spine imaging within 6 weeks after an initial visit for care for LBP versus similar patients who did not undergo early imaging It is well documented that imaging patients with chronic LBP is often not beneficial and similar imaging findings are often present in asymptomatic individuals. Additionally, patients with new episodes of LBP and previous MRI scans are unlikely to detect changes in disc protrusion, annular fissures, high-intensity zones, or end-plate signal changes with repeated MRI. The medical literature and the guidelines recommend conservative therapy, both pharmacologic and nonpharmacologic, prior to initiating further imaging studies. This patient is documented to have a relatively new onset of low back pain, and in the absence of pre-existing conditions such as a tumor or indications of an acute infection, the most prudent approach is to proceed conservatively. The documentation does not show that he has exhausted conservative management.  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 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for wound debridement, wound VAC, and flap technique to close the wound. The enrollee has also requested authorization and coverage for inpatient hospitalization services until the enrollees wound is stabilized medically.The submitted documentation does not support that the requested services are medically necessary. Researchers state that a fundamental way in which nurses and care staff may contribute to maximizing the healing potential of existing pressure ulcers is by repositioning those patients who are unable to reposition themselves. They state that international best practice advocates the use of repositioning as an integral component of a pressure ulcer prevention and management strategy. Research states that one should consider autolytic debridement with appropriate dressings for dead tissue and consider sharp and surgical debridement by trained staff if autolytic debridement is unsuccessful.In this case, the patient has multiple medical conditions as well as a stable sacral wound. Elective surgery to surgically debride, excise, and close a stable sacral decubitus is not indicated. Wound debridement, wound VAC, and flap technique to close the patients wound is not medically necessary to treat the enrollees condition and would be contraindicated. The sacral decubitus is not a significant medical problem in view of the patients medical condition. It is stable and not infected.  It does not require inpatient hospitalization for treatment, and inpatient hospitalization services until the patients wound is stabilized medically is not necessary to treat the patients condition. Therefore, wound debridement, wound VAC, and flap technique to close the wound are not medically necessary to treat the patients medical condition, and inpatient hospitalization services until the patients wound and infection are stabilized are not medically necessary to treat the patients medical condition.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.