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

A 43-year-old female enrollee has requested for urgent care services on an urgent basis. Findings:  The physician reviewer found that she was ultimately diagnosed with hypertension (which was evidently new from her prior visit), obesity and fluid retention. This was evaluated with a chemistry panel, and she was discharged with a diuretic. This patients symptoms were severe enough for a prudent layperson to seek urgent care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of urgent care to jeopardize her health.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee requested medical marijuana for treatment of her anxiety.  Findings:  The physician reviewer found that the use of medical marijuana for the treatment of anxiety is not endorsed by the American Psychiatric Association.  Further, there is a lack of well-designed, adequately powered studies in the peer-reviewed medical literature demonstrating both the safety and efficacy of medical marijuana for treatment of anxiety in human populations.  Finally, regarding this particular patient, there was no mental health documentation provided.  Critical documents such as a psychiatric history, comprehensive treatment plan, serial progress notes with clinical rating scales, and the status and outcomes of prior or concomitant treatments, such as services provided at alternative levels of care, community programming or evidence-based interventions for anxiety such as pharmacotherapy and cognitive behavioral therapy, were not included for review.  In sum, there is a lack of clinical justification supporting the use of medical marijuana as a treatment intervention for an anxiety disorder.
Appeal type: Medical Necessity
Decision: Upheld

An 85-year-old male enrollee requested Lyrica for medical treatment of his sciatica.   Findings:  The physician reviewer found that  per prescribing information, Lyrica is indicated for patients with epilepsy or seizure, diabetic peripheral neuropathy, post herpetic neuralgia, neuropathic pain due to spinal injury, or fibromyalgia. This patients records do not include documentation that this patient has any of these approved indications for Lyrica. Consistent with the prescribing information and without significant studies in response of Lyrica in low back pain, the requested medication is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested authorization and coverage for high intensity focused ultrasound (HIFU), or in the alternative, cryotherapy. Based on peer-reviewed medical literature and guidelines, standard techniques including radiation therapy and surgery are the most effective intervention options for this patients prostate cancer. Current literature does not support HIFU or cryotherapy in lieu of conventional techniques in this clinical setting. HIFU and cryotherapy may be considered in patients who have progressed despite treatment with proven interventions. The records do not report that the patient has failed treatment with radiation therapy or surgery. HIFU and cryotherapy are not likely to provide this patient with improved disease control and quality of life when compared to standard available therapies. For these reasons, the requested HIFU, or in the alternative, cryotherapy is not 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 services are 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, and 3 are board certified in urology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing provided. Findings:  The physician reviewer found that  in this circumstance, guidelines for the management of cardiac risk and dyslipidemia 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, sub-classifications of low-density lipoprotein, high-density lipoprotein subclasses, lipoprotein (a), C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine.  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.  Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results.  In sum, advanced lipoprotein testing provided  was not likely to have been more efficacious than other methods of evaluating this patient.Final Result: The 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: Physician reviewers 1, 2 & 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for magnetic resonance imaging (MRI) of the lumbar spine. The American College of Radiology appropriateness criteria for low back pain notes that for subacute or chronic low back pain with or without radiculopathy, without red flags, or prior management or imaging, an MRI of the spine without contrast is usually not appropriate. The guidelines further note that for elderly patients, computed tomography (CT) is preferred, although MRI can be useful to evaluate for ligamentous injury or worsening neurologic deficit. Additionally, findings on MRI may not necessarily correlate with symptoms as a patient may have incidental findings on an MRI that are not symptomatic, and, conversely, may have relatively unimpressive findings on an MRI while experiencing significant symptoms. In this case, the records do not document specific signs of motor or sensory deficits. The submitted documentation did not indicate that the patient was being considered for surgery, that imaging studies would change the course of the patients management, that conservative management with physical therapy, focused exercises, and anti-inflammatory medications had been tried without relief, or prior imaging such as plain x-rays or CTs. Given that the records did not indicate that a surgical procedure was appropriate and as an intensive conservative approach to therapy was first warranted, the service at issue was not medically indicated. Therefore, MRI of the lumbar spine was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for radiofrequency ablation (RFA) of bilateral sacroiliac (SI) joint.  According to the medical record, the enrollee has a history of lumbar stenosis, lumbar radiculopathy, lumbar facet arthropathy, and sacroiliitis causing low back pain that radiates down both legs. He was referred to a pain management physician and was treated with radiofrequency ablation (RFA) that helped with his pain and provided relief for 12 to 18 months. The medical literature has limited support for this approach with mostly case series and case reports confounded with multiple techniques and short term follow-up. There is minimal clinical benefit from radiofrequency ablation of the sacroiliac joint in randomized trials.  Studies are limited by small numbers of enrollees, varying techniques and prominent placebo effects.  Final Result: Three of the three reviewers determined the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in pain management 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: Overturned

A 55-year-old male enrollee has requested a neurography test for evaluation of his left hip abductor weakness. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the services requested. The patient has had acute development of abductor weakness in the left leg post hip surgery, with residual gait alteration. The EMG revealed signs of L5-S1 radiculopathy, but cannot exclude gluteal nerve damage that would fit the clinical scenario. According to Pham and colleagues, MRN can be very useful in precisely determining the site of sciatic injection injury and may provide diagnostic criteria for the assessment of lesion severity and recovery. In addition, Petchprapa and colleagues state that cross-sectional imaging, particularly magnetic resonance (MR) imaging and specifically MR neurography, plays an increasingly important role in the work-up of entrapment neuropathies. Therefore, an MRN at this point may help clarify whether the residual weakness is a consequence of surgery, or due to unrelated spinal stenosis. This can clarify prognosis and future decisions regarding possible spinal surgery and is thus medically necessary. All told, the medical necessity of the requested study has been established.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-month-old male enrollee requested intravenous immune globulin (IVIG) treatments for treatment of the enrollees immune deficiency.  Findings:  The physician reviewer found that the patient does have otitis requiring antibiotics and failure to respond to bacterial and viral vaccinations. His supplementary studies suggest high cell turnover with significant ongoing inflammation and probably an intracellular signaling defect blocking his ability to make effective antibodies. While other possibilities such as leukocyte adhesion deficiency or a toll-like receptor defect are possible, it is medically necessary to treat this patient with IVIG treatments for 6 to12 months while more definitive studies are completed.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an eleven year-old female with a height below the 3rd percentile is requesting authorization for GH therapy.  The patient took part in a research study and was treated with GH. The documents provided indicate the growth rates, but do not include any biochemical results or bone ages.Reviewers Findings:The reviewing physician found that in order to establish medical necessity for GH therapy, a recent bone age with an accurate height measured near the time of the X-ray is needed so that an adult height prediction can be made.  This information is not present in this case.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old female enrollee requested authorization and coverage of VNUS closure and microvascular excision with ligation of perforating veins. The Health Plan denied the request indicating that the requested procedures are not medically necessary for treatment of the enrollees varicose veins.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedures are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the fecal calprotectin testing for evaluation of the enrollees possible inflammatory bowel disease. Findings:  The 3 physician reviewers found that the use of fecal calprotectin testing to diagnose change in bowel habits has not been accepted for routine use in this clinical setting. According to the American College of Physicians (ACP) a specialist might measure fecal calprotectin, but only in conjunction with detailed history-taking, clinical examination, and serum inflammatory markers or other blood tests, to determine the need for endoscopic evaluation. The ACP also stated that fecal calprotectin is elevated in several other gastrointestinal diseases, including viral, bacterial, and protozoal causes of infective diarrhea. The impact of this laboratory test on management and its appropriateness in guiding therapy decisions in patients with unexplained diarrhea has not been demonstrated. The findings can be redundant with standard methods of diagnosis, such as colonoscopy or sigmoidoscopy, or other serum markers of inflammation. Guidelines on the diagnosis and management of diarrhea do not recommend calprotectin as part of the investigation. A recent meta-analysis of inflammatory bowel disease markers reported that the relatively poor specificity of fecal calprotectin in Crohns disease is a concern, as a false positive test could lead to treatment of a patient without endoscopically active disease.  For these reasons, the fecal calprotectin testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: The 3 reviewers determined that the testing at issue was 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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

The patient is a 45 year-old male who is status post anterior cruciate ligament (ACL) reconstruction in April 2006 for a torn ligament and medial meniscus. The record indicates he progressed well with physical therapy, but a knee brace was recommended for more demanding physical activities such as sports, yard work and occasional job requirements. The enrollee submitted a request for authorization of a custom knee brace. The Health Plan denied his request based upon a determination that the equipment is not medically necessary.According to the records provided for review, the patient had a non-complicated ACL reconstruction with no evidence of postoperative instability. The physical therapy note of June 2006 did not document symptoms such as his knee giving way or weakness with jogging, high knee stepping, quick reversals or side shuffle. Additionally, it would appear the brace was prescribed primarily for sports activities. There is no evidence in the peer-reviewed clinical literature that prophylactic bracing prevents re-injury in an otherwise stable postoperative knee.Based upon the information set forth above, I have determined the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 19-year-old female enrollee has requested for continued residential treatment for treatment of her behavioral health problems. Findings:  The physician reviewer found that the mothers position regarding medication has taken control away from the treating psychiatrist and the patient. Follow-up by her primary healthcare physician, as well as intensive expert 1:1 outpatient psychological treatment, psychiatric follow-up, and ongoing family therapy appears to this reviewer to be the most practical option and chance for improvement, compared with the continuation of residential treatment given the current situation. Ultimately, until the mother and patient can agree to cooperate with the physicians recommendations, no further treatment will likely succeed. Psychiatric practice guidelines stress the importance of the patients decision regarding compliance with treatment on the final outcome.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for excimer skin laser therapy two (2) times weekly. Several studies show the benefits of excimer laser therapy when first-line treatments have failed. Researchers found that excimer laser therapy can safely and effectively be used in the treatment of the prurigo form of atopic dermatitis, and for the long-term, may be an option in the case of therapy-resistant patients. Scientists noted, Phototherapy is a second-line treatment for moderate to severe atopic dermatitis that effectively decreases cutaneous inflammation with minimal or no systemic side effects. Researchers noted that, excimer laser and excimer lamp might be the best option for clearing localized therapy-resistant lesions. Studies found that excimer light treatment significantly changed the composition of the bacterial microbiome in the lesional skin of atopic dermatitis, possibly leading to improvement. In this case, the patients dorsal foot eczema was described as thick, had been present for 15 years, and had failed multiple therapies. The condition had not responded to a potent topical steroid, clobetasol, applied with wet wraps. Due to her pregnancy, the patient is a poor candidate for systemic therapy, and excimer laser therapy in addition to a strong topical steroid regimen is likely the safest treatment option. Therefore, the requested excimer skin laser therapy two (2) times weekly is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two out of three medical experts decided that excimer skin laser therapy two (2) times weekly 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 services are 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: Physician reviewers 1, 2, and 3 are board certified in dermatology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for dual x-ray absorptiometry (DEXA). The Health Plan has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees medical condition.Trabecular bone score (TBS) is a recently developed analytical tool that performs novel grey level texture measurements on lumbar spine dual x-ray absorptiometry (DEXA) images, and thereby captures information relating to trabecular microarchitecture. The medical literature indicates that this technique adds information to bone mineral density. TBS has been shown to have predictive value for fracture independent of fracture probabilities using the FRAX algorithm. The National Osteoporosis Foundation guidelines indicate that patients taking U.S. Food and Drug Administration approved medications should have laboratory and bone density re-evaluation after two years or more frequently when medically appropriate, which is the case with this patient. Per the National Osteoporosis Foundation guidelines, a DEXA scan to assess the effectiveness of medical therapy at two years or more frequent intervals, is medically appropriate in this clinical setting.  In sum, based on the current medical literature as well as the documentation provided, the requested DEXA scan has been demonstrated as medically necessary for the evaluation of this 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 sub-specialty certification in endocrinology, diabetes and metabolism and expertise in transgender care 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.