Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee requested surgical services and related services on an emergent basis.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with chronic pelvic pain secondary to ruptured ovarian cysts and endometriosis and underwent a complex laparoscopic surgery. The operative note documents concern for the severity of the patients pain. Ovarian torsion is considered the most common gynecological emergency. Given the acute severity of the patients pain, abnormal MRI and pelvic ultrasound, a prudent layperson in this circumstance would reasonably believe she was suffering from a serious medical condition. In sum, the patient was suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services provided on the date in question met prudent layperson criteria for emergency care.Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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: A patient has requested authorization and coverage for treatment at a tertiary level facility. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients malignant neoplasm of the left breast. The submitted documentation does not support the medical necessity of the requested services. Breast cancer is the most common type of cancer in women. Treatment algorithms are standard across institutions, unless patients are enrolled in a clinical trial. There is a clear standard of care for the adjuvant treatment of breast cancer, The records do not document that this patient has plans to participate in a clinical trial. Therefore, the patient would receive similar care wherever the patient is treated. There are medical oncologists available within her network. Therefore, treatment at a tertiary level facility is not medically necessary for the 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 internal medicine with sub-specialty certification in medical oncology 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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for a continuous positive airway pressure (CPAP) machine for treatment of the enrollees sleep apnea. Findings:  The physician reviewer found that there is sufficient support for the equipment at issue in this clinical setting. The American Academy of Sleep Medicine (AASM) recommends offering positive airway pressure therapy to all patients who have been diagnosed with obstructive sleep apnea.  Obstructive sleep apnea is defined as either an obstructive respiratory disturbance index greater than or equal to 15 events per hour with or without symptoms, or an obstructive respiratory disturbance index between 5 and 14 events per hour that is accompanied by symptoms of uncontrolled obstructive sleep apnea, such as sleepiness, fatigue, hypertension, heart disease, diabetes mellitus type II or cognitive or mood disorders. In this case, the patients apnea index is 7 with an abnormal respiratory disturbance index of 45.3, which is consistent with significantly severe obstructive sleep apnea. The documentation available for review supports that she consistently uses the CPAP machine four hours or more per night on most nights. The current medical evidence supports the equipment at issue in this clinical setting. All told, CPAP machine was and is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the equipment at issue was and 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 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 magnetic resonance cholangiopancreatography (CPT code 74181) of the abdomen.Idiopathic acute pancreatitis is acute pancreatitis in which workup has not revealed a cause. A variety of causes, including anatomic defects, biliary disease, and autoimmune disease are possible In patients with idiopathic acute pancreatitis, magnetic resonance cholangiopancreatography (MRCP) can lead to a diagnosis when other testing has not done so, and can find causes not apparent even on endoscopic ultrasound, which entails procedural risk and requires undergoing sedation  One study showed that when MRCP is used in combination with endoscopic ultrasound, the rate of idiopathic acute pancreatitis is reduced by 66%  A systematic review and meta-analysis comparing MRCP with endoscopic ultrasound concluded that endoscopic ultrasound and MRCP should both be used in the diagnostic work-up of idiopathic acute pancreatitis as complementary techniques, and that MRCP was superior to endoscopic ultrasound in diagnosing anatomic alterations in the biliopancreatic system (such as pancreatic divisum) which can cause acute pancreatitis. In this case, the patient has been diagnosed with idiopathic acute pancreatitis, and other testing and evaluation, including ultrasound of the abdomen, has not revealed a cause. Under these circumstances, the requested magnetic resonance cholangiopancreatography (CPT code 74181) of the abdomen is medically necessary to treat the patients medical condition.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 internal medicine, with subspecialty 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: The patient has requested authorization and coverage for durable medical equipment (RT 300 FES therapy system). Findings:  The physician reviewer found that There is a lack of evidence in current medical literature demonstrating that exposure to passive exercise, such as would be provided by the requested device, improves function or health outcomes in a clinically significant manner for neurological conditions, including complete traumatic paraplegia. Hofer and Schwab report that while treatment options using neurostimulation to enable or enhance intense training appear promising, regaining lost motor function remains challenging, and characterizing long-term benefits and side-effects in clinical trials also remains crucial. Ralston and colleagues noted that in a study of 14 patients with recent spinal cord injury, there were no clear effects of FES cycling on increasing urine output, decreasing lower limb swelling and spasticity. Mayson and Harris note that more rigorous research involving a greater number of participants is needed before determining the efficacy of FES cycling as an intervention for youth with spinal cord injury. Tweedy and colleagues note that patients with traumatic spinal cord injury benefit from active exercise using volitionally intact muscles, and the general encouragement of active participation in educational, social, recreational, avocational and vocational activities. Given that current medical literature does reflect that the use of the requested device would improve cardiovascular health, pulmonary health or other health parameters in any clinically significant manner, the requested device is not medically indicated. Therefore, durable medical equipment (RT 300 FES therapy system) is not medically necessary for the treatment of this patient.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

A 51-year-old female enrollee has requested for Synvisc injections for treatment of her knee pain. Findings:  The physician reviewer found that the condition of the patients knee has changed since she last had viscosupplementation. She remains symptomatic, requiring narcotic analgesics. Cortisone injections have been minimally successful, and she is young for knee replacement. A series of Synvisc injections is clinically reasonable in this setting. Past treatment with Synvisc does not preclude additional benefit from this therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 60-year-old female enrollee has requested for dynamic surface electromyography, physician review and interpretation of comprehensive computer based motion analysis, dynamic plantar pressure measurements for treatment of her medical condition.   Findings:  Three physician reviewers found that review of the literature shows that gait analysis testing is standard in optimizing ambulation in a variety of conditions, including after amputation, as well as post stroke, post trauma, and multiple sclerosis. As a result of her gait analysis, the patient was fitted with ambulatory prosthetics, with resultant improvement in her gait. The diagnostic testing that was performed (gait analysis with surface EMG and physician interpretation) was not experimental or investigational in nature for this patients particular clinical situation and was clinically indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for mepolizumab (Nucala) 300 mg subcutaneously, every four weeks for one year. Findings:  The physician reviewer found that Mazori and colleagues report that eosinophilic fasciitis is a fibrosing disorder, and that first-line treatment is with systemic corticosteroids. The authors report that in a search for adjunctive therapies, methotrexate has emerged as the leading corticosteroid sparing agent for the treatment of eosinophilic fasciitis. Due to the rarity of eosinophilic fasciitis, there is a lack of randomized trials on therapies for the treatment of this condition. While there is support in current medical literature for first-line treatment with high dose system steroids, followed by immunosuppressive therapies including methotrexate, Cellcept, azathioprine, cyclosporine and even biologics such as infliximab and tocilizumab, there is a lack of evidence supporting the successful use of mepolizumab (Nucala) in the treatment of eosinophilic fasciitis. Therefore, mepolizumab (Nucala) 300 mg subcutaneously, every four weeks for one year, is not medically necessary for the 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 sub-specialty certification in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested hyaluronate viscosupplementation injections for treatment of her medical condition.  Findings:  The physician reviewer found that the current medical evidence supports the requested services in this clinical setting.  Researchers performed a meta-analysis of 137 studies with 33,243 participants and concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis.  Hyaluronic acid was found to be better than injected placebo or injected corticosteroids.  Another researcher conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee.  This patient has been diagnosed with severe bilateral knee osteoarthritis.  She has undergone prior series of viscosupplementation injections with significant benefit documented both in terms of pain reduction and improvement in functional ability.  There is documentation that prior conservative treatment, including physical therapy and medications, have failed to provide benefit.  Therefore, the requested hyaluronate viscosupplementation injections are medically indicated 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 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 breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Tomosynthesis brings advantages to providers in the interpretation of mammograms.  These advantages relate to the ability of providers to often separate architectural distortion from dense glandular breast tissue or scar. Thus, the addition of tomosynthesis to the usual two-dimensional (2D) mammographic images was likely of more benefit to the patient than if the mammogram had been done with 2D imaging only.    Final Result: Two reviewers determined that the diagnostic procedure 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 reviewers are board certified in diagnostic radiology and are 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

A 43-year-old female enrollee requested authorization and coverage of proton beam radiation therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees brain tumor.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a five-month-old female enrollee has requested occupational therapy for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that children with Down syndrome may have medical vulnerabilities and congenital abnormalities that occur in greater frequency (Cohen; American Academy of Pediatrics; and Rasmussen, et al.). As a result, the prevention of secondary disability is important. Occupational therapy with early intervention services is often needed for continued improvement in fine-motor skills acquisition and helps to promote arm and hand movements that lay the foundation for later developing fine motor skills (Cohen and Rasmussen, et al.). Occupational therapy helps to provide initial learning steps for feeding and dressing independently. The long-term benefit of occupational therapy is that it helps prevent compensatory movement patterns that individuals with Down syndrome are prone to developing (American Academy of Pediatrics). This patient does not currently have significant, identified fine motor delays. Given the patients young age, re-evaluation of fine motor and adaptive abilities is recommended in four months. If delays greater than 25% are noted at that time, occupational therapy would be indicated and medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Linzess for treatment of the enrollees constipation. Findings:  The physician reviewer found that the American Gastroenterological Association (AGA) and American College of Gastroenterology state that if an osmotic agent such as Miralax and then another type of laxative fail, a newer agent such as Linzess or Amitiza should be considered. The patient has responded well to Linzess and there is no bowel obstruction reported in this case. For these reasons, Linzess is supported as medically necessary for the treatment of the patients irritable bowel syndrome with constipation. 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested inpatient psychiatric services for treatment of the enrollee's behavioral health condition. Findings:  The physician reviewer found that the patient was not actively suicidal and had no acute comorbid substance use or medical issues that were identified.  The patient was scheduled to see her psychiatrist and it is reasonable that she could have been maintained in the community until the psychiatric appointment.  The records do not demonstrate that the patient required hospitalization with 24-hour nursing or physician monitoring.  All told, inpatient psychiatric services were 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 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 Harvoni for 12 weeks for treatment of her hepatitis C.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  Harvoni has been shown to be effective in this clinical setting.  Based upon the American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, immediate treatment with the highest priority is recommended for this patient with compensated cirrhosis.  All told, Harvoni for 12 weeks is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in 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.