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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for RTC level of care services. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to continued suicidal ideation, with a history of a past suicide attempt, and substance use.  In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to conflict with parents and weight loss while at the RTC. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of substance abuse.In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment due to stress related to family conflict. With regard to level of support of the recovery environment, the records support a score of 2 due to the parents participation in family therapy and treatment planning.In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment, due to lack of improvement in mood, anxiety, and substance abuse and recurrence of weight loss despite prior inpatient hospitalization, outpatient therapy, medication trials, and six weeks of PHP treatment. With regard to treatment acceptance and engagement, the records support a score of 2. The patient was cooperative in her treatment at the RTC. Thus, the patient has a total score of 20. The harm risk score of 4 supports care at Level 5, medically monitored residence-based services. This is consistent with the level of care that the patient received and is receiving at the residential treatment center. Therefore, RTC level of care services were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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 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

The patient is a 43-year-old male with recurrent gout for the past two years. He had been appropriately referred to a rheumatologist for management of his gout. Once the patients acute symptoms were controlled, the Health Plan determined the patients PCP could manage the patient further. Subsequently, a change in the patients medication resulted in a recurrent acute attack of gout. The Health Plan indicates continued care with a rheumatologist for management of the patients gout is not medically necessary.Of all rheumatologic conditions, gout may be the most eminently and effectively manageable. With appropriate treatment, and in the absence of allergy to Allopurinol, gout should be suppressed well enough that no further acute episodes occur in a given patient.It can be very difficult to effectively manage gout as a chronic recurring condition. Practitioners are often unable to avoid the many pitfalls that exist in the management of gout including: lack of understanding of serum uric acid levels, which have little relevance to diagnosis, and much greater importance for monitoring treatment; incorrect timing and dosing of Allopurinol treatment; failure to maintain suppression with low-dose Colchicine until the serum uric acid level is adequately lowered; overuse of NSAIDs long-term; incomplete understanding of treatment goals; and failure to maintain long-term suppression.The patients rheumatologist correctly lowered, but did not discontinue, the patients Colchicine dose. The rheumatologist also began monitoring the patients serum uric acid level, which was apparently 7.9% at the onset. Although the patients acute episode was controlled, his serum level was not. When the patient returned to his PCP Colchicine was discontinued. Thereafter, the patient experienced another acute episode of gout, after his serum level had dropped only to 7.2mg.The submitted documentation demonstrates the patients gout is not adequately controlled and does not meet the standard of care in rheumatologic practice. The patient should continue to be followed by his rheumatologist at intervals of two to three months until his clinical gout, laboratory markers, and medication regimen are controlled and stabilized. Therefore, I have determined that the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: There is lack of support in the medical literature for the medical necessity of the services at issue in this clinical setting. The American Society of Addiction Medicine (ASAM) criteria is an accepted, national standard for determining the appropriate level of care for adults with substance use problems. This criteria was used to assess the appropriate level of care in this patients case. On 9/21/16, the patient was having mild anxiety from withdrawal of alcohol. He was medically stable and was not undergoing severe withdrawal symptoms. The documentation did not report that the patient had homicidal or suicidal thoughts. Under Dimension 1, the patients score is a 1, which correlates to acute intoxication and/or withdrawal potential. Under Dimension 2, which correlates to biomedical conditions and complications, the patients score is a 1. The patient had elevated liver function enzymes, but it does not appear that the patient was symptomatic. Dimension 3 measures emotional, behavioral or cognitive conditions or complications medical/addictive/psychiatric co-morbidities. The patients score is a 2. The patient had defense mechanisms that distracted from recovery efforts, but there was not an immediate threat to safety, and this did not prevent independent functioning. Dimension 4, correlates with readiness to change. The patients score is a 2. The patient was reluctant to agree to treatment and was passively involved in treatment. Under Dimension 5, which correlates to relapse, continued use or continued problem potential, the patients score is a 2. The patient had impaired recognition and understanding of potential substance use relapse issues, but was able to self manage with prompting. Dimension 6, recovery/living environment is scored a 1. The patient was struggling in his marriage. However, the patient did have family support who put together the intervention. On 9/21/16, based on the ASAM criteria, the patient could have been treated in an intensive outpatient program (IOP). The patient did require treatment for his alcohol use disorder, but this could have been performed in a less restrictive environment. Therefore, the residential treatment center services from 9/21/16 through 10/14/16 were not medically necessary for treatment of this 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 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

A 55-year-old female enrollee has requested an Austin bunionectomy step down with internal fixation on her right foot for the treatment of her foot pain. Findings:  The physician reviewer found that there are different medical opinions as to how to alleviate the patients foot pain and correct her hallux limitus. While both joint arthrodesis and an Austin bunionectomy step down with hemi implant are viable options for correction of hallux limitus, the latter (hemi implant) will preserve joint motion. The requested procedure is medically necessary for treatment of this patients condition and would be the superior treatment versus the joint arthrodesis. Joint preservation will allow for unencumbered ambulation.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the UroLift prostatic urethral lift procedure for treatment of the enrollees benign prostatic hyperplasia (BPH). Findings: The three physician reviewers found the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The peer-reviewed literature including prospective sham controlled randomized studies have shown that the UroLift system is safe and effective in relieving lower urinary tract symptoms due to BPH (Roehrborn, et al). Given the support in the peer-reviewed literature, the request for UroLift prostatic urethral lift procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in urology and are actively practicing. The reviewer 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

A 64-year-old male enrollee requested skilled nursing facility (SNF) services including physical therapy and occupational therapy for medical treatment of his medical condition status post syncope and collapse with coccyx pain likely secondary to fall. Findings:  The physician reviewer found that the Centers for Medicare and Medicaid Services (CMS) indicate that when the daily presence of a skilled therapist is no longer necessary, daily inpatient therapy is no longer supported as medically necessary. Continued progress can be achieved with continued exercise without daily supervision from a skilled therapist (Ward, et al). This patients records indicate that he had reached a level of function that did not require daily skilled therapy to restore or maintain function.  The patient was able to move in bed, walk, and transfer from bed to chair and from chair to standing without hands on support.  There were no daily skilled nursing needs.  All told, the SNF services   were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement for inpatient hospital level of care. The records document that this patient had a history of left knee trauma with persistent moderate to severe pain and mechanical symptoms. Magnetic resonance imaging (MRI) showed a lateral meniscal tear with parameniscal cyst. The patients condition failed to improve despite reasonable and comprehensive conservative treatment. The patient underwent a meniscectomy and cyst excision and was discharged from the hospital on the same day. Evidence based medical literature supports full inpatient admission given that the ambulatory care center was unable to manage patients with markedly elevated BMIs, and the increased risk factors associated with obesity and hypertension in this patients case. Given these findings, the inpatient hospital level of care was medically necessary for 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  Three physician reviewers found that the enrollee was asymptomatic with respect to her breasts.  She has a history of having had a prior cyst aspiration of her left breast, and a core biopsy of her right breast.  She also has a family history of breast cancer in her mother.  The current images were compared to prior mammograms, and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  Her breast tissue was described as dense.  The Health Plan has denied reimbursement for digital breast tomosynthesis. Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, the records document dense breast tissue.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Final Result: Three reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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: Urgent Care
Decision: Overturned

A female enrollee requested ambulance transportation required on an emergent or urgently needed basis. Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. In this case, the patient called 911 as she was concerned for her health with progressive symptoms. Further, it has been established that criteria for urgently needed services were met on the date in dispute. In sum, based on the patients clinical presentation she did meet prudent layperson criteria for urgently needed services.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee requested authorization and coverage of a capsule endoscopy for the treatment of abdominal pain.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that a capsule endoscopy is not likely to be more beneficial for treatment of the enrollees abdominal pain than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Experimental/Investigational
Decision: Upheld

A 69-year-old male enrollee has requested Oasis Neuromonics Therapy for the treatment of his tinnitus. Findings:  Three physician reviewers found that tinnitus is a common condition which affects many patients with hearing loss. A small number of patients find the tinnitus severe enough to affect quality of life. To date, there has been no recognized consistently successful treatment for this condition. Neuromonics therapy is a recent attempt to treat this problem and may prove successful with future trials. Currently, outcome data is limited and there is insufficient evidence to be able to conclude that Oasis Neuromonics Therapy represents an effective treatment modality for tinnitus. Larger scale outcome studies need to be performed before Neuromonics therapy can be considered beneficial. At this point, it has not been demonstrated that the proposed therapy will result in greater improvement in the patients symptomatology than standard alternatives in this setting.
Appeal type: Experimental/Investigational
Decision: Overturned

A 49-year-old male enrollee has requested the LINX procedure for treatment of his gastroesophageal reflux disease. Findings:  Two physician reviewers found that the requested services are likely to be more effective than other treatment options.  Per the current medical evidence, treatment of the anatomic defect is warranted due to persistent acid reflux.  LINX is a minimally invasive anti-reflux procedure which is less invasive and involves fewer side effects.  Additionally, the LINX procedure is potentially reversible.  There is sufficient support in the current medical literature for the services at issue.  Thus, the requested LINX procedure is likely to be of greater benefit than other treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld

A 21-year-old female enrollee requested authorization and coverage of an insulin pump. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees diabetes.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for anesthesia services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees family history of colon cancer.At issue is whether the anesthesia services provided were medically necessary. Most lower endoscopy can be accomplished with either no, moderate, or deep sedation; general anesthesia and active airway management are rarely needed. Propofol-based sedation has advantages in terms of satisfaction and recovery over other modalities, but moderate sedation using benzodiazepines and opiates works well for low-risk patients and procedures. No sedation for routine colonoscopy works well for selected patients and eliminates sedation-related risks. There is no difference in outcome measures based on sedation received. Researchers noted that anesthesia assistance has potential complications including aspiration pneumonia but increased patient satisfaction in some cases.The patient has a family history of colon cancer but is otherwise healthy and may be classified as an ASA I patient for anesthetic purposes. MAC (monitored anesthesia care) anesthesia is medically necessary for patients with severe medical conditions including heart and lung disorders and not for relatively healthy, ASA I patients. The medically necessity of monitored anesthesia care cannot be justified in this case. Thus, the anesthesia services at issue were not medically necessary.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 anesthesiology 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 patient has requested authorization and coverage for Remicade infusions. Findings:  The physician reviewer found that the diagnosis of Crohns disease has been reasonably established in this case by colonoscopy results and consistent clinical symptoms. This patient has moderate to severe Crohns disease due to severity of symptoms and age at diagnosis. The American Gastroenterological Association (AGA) guidelines for induction of remission in moderate to severe disease recommend anti-tumor necrosis factor (TNF) inhibitors including Remicade. For maintenance of remission, treatment with TNF inhibitors are strongly recommended by these guidelines based on level 1 evidence. Uncontrolled disease flares can rapidly result in complications. Based on this patients records, she needs treatment expediently to treat an active disease flare and to avert complications of Crohns disease. Therefore, the request for Remicade infusions is supported as medically necessary for the treatment of the patients Crohns disease. 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 63-year-old female enrollee has requested continued chiropractic office visits for treatment of her bilateral low back pain, right hip pain and severe low back stiffness. Findings:  The physician reviewer found that there is insufficient clinical documentation that supports the medical necessity of the services at issue in this patients case. The submitted records lack documentation of progression of care, clinical impressions and assessment of the patients condition and treatment effectiveness visit to visit.  The documentation provided does not indicate a review of chief complaints and changes since the last office visit. There is notation that the patient was given lumbar/cervical and Williams lower back stabilizing exercises, with no indication of how the patient was progressing with these activities.  The records do not include any palliative and/or provocative assessment visit to visit. Per the submitted documentation, continued chiropractic office visits were not and are not medically indicated.