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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orencia. This patient with minimal change disease has reportedly failed treatment with mycophenolate and could not tolerate calcineurin inhibitors (CNIs). Studies noted that minimal change disease is a major cause of idiopathic nephrotic syndrome (NS), characterized by intense proteinuria leading to edema and intravascular volume depletion. However, the medical literature does not support a role for Orencia in the treatment of minimal change disease. Ongoing studies are being conducted to establish the efficacy and safety of Orencia in the treatment of minimal change disease. Therefore, the requested Orencia is not supported as medically necessary for treatment of this patients minimal change disease. 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 subspecialty certification in nephrology 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 the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  Two physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a power wheelchair for treatment of his backache.  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested power wheelchair. Auger and colleagues performed a literature review of power wheelchair usage and assigned most of the research designs as very low quality. A poor foundation of evidence challenges the provider tasked with determining the medical necessity of a power wheelchair for a specific patient. Power mobility can benefit specific patients, however in the present case there is a lack of evidence supporting the medical necessity for power mobility. The patient does not have any obvious medical indication for a power wheelchair. He can ambulate within his abode and he can ambulate with or without assistive devices. Additionally his abode is not wheelchair accessible. Based on the clinical documentation submitted, a power wheelchair is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested equipment is 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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:  The parent of an enrollee has requested residential behavioral health services for treatment of the enrollees behavioral health condition.   Findings:  The physician reviewer found that the requested residential behavioral health services were not and are not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, there is a lack of support demonstrating symptoms or interventions which would require 24-hour level of monitoring for this patient. There is a lack of evidence demonstrating mood dysregulation which would prevent him from safely continuing at a lower level of care. Moreover, there is a lack of evidence to support that the patient has a psychiatric disorder that affects all areas of functioning that require residential level of care. All told, the patient could have been safely treated at a lower level of care.  Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications:  The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer.  Findings: Two physician reviewers found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. Accordingly, the breast tomosynthesis that was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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 physician reviewers are certified in diagnostic radiology and is actively practicing. The reviewers are 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

An 18-year-old male enrollee has requested an i-Limb prosthetic hand for the treatment of his medical condition status post left hand amputation. Findings:  The physician reviewer found that the prescription of an upper limb prosthesis is highly individualized and must be client-centered in order to achieve a positive clinical outcome (Biddiss and Chau). Desmond and MacLachlan indicate that the treating team must consider multiple factors including the patients clinical status and psychological needs, the functionality of the device, and his or her functional needs. In the absence of such an approach, the likelihood that the patient will successfully use the prosthesis is greatly diminished. In the case of this patient, the records demonstrate that he will derive significant benefit from the enhanced ability to perform fine motor tasks that the i-Limb provides. The submitted records justify the need for a myoelectric prosthesis as well as the unique capabilities of the i-Limb hand prosthesis. A cable operated alternative is contraindicated due to the patients shoulder, neck and back pain.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old female enrollee has requested hyperthermic intraperitoneal chemotherapy (HIPEC) for treatment of her ovarian cancer.  Findings:  Three physician reviewers found that based on the clinical history presented for review, the request for HIPEC would be in the setting of ovarian cancer therapy consolidation. Currently, there have been multiple publications of small groups of patients that show some promise with HIPEC in the recurrent setting. There are several prospective randomized trials that are evaluating HIPEC in ovarian cancer, but these are ongoing. HIPEC has not been evaluated as a method of consolidation therapy. Given the paucity of peer-reviewed data demonstrating the safety and effectiveness of HIPEC over standard alternatives, it should only be offered in the setting of a clinical trial.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cosentyx for treatment of the enrollees plaque psoriasis. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. In this case, the patient has chronic plaque psoriasis and has failed many standard therapies. Light therapy requires three times weekly treatment and this patient would have to drive over 60 miles to get treatment three times a week, which is not reasonable for a five minute treatment. In addition, the use of cyclosporine is not medically appropriate to be used long-term for control of a chronic plaque psoriasis. Also, the patient has elevated lipid levels and is treated with Lipitor. Treatment with acitretin is contraindicated for this patient as acitretin is known to have frequent side effects for patients with elevated lipid levels. Lastly, since the patient regularly consumes alcohol, treatment with Cosentyx is medically appropriate given that the patient will not have an adverse effect on the liver that may occur with methotrexate. 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 dermatology 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 Epclusa 400-100 mg for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that The physician reviewer found according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies in all cases, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as a first-line regimen for non-cirrhotic, treatment-naive, genotype 3 patients. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. All told, Epclusa 400-100 mg for 12 weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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: Overturned

An enrollee has requested reimbursement and authorization and coverage for residential treatment center services. The American Society of Addiction Medicine (ASAM) criteria is a validated placement tool. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Based upon the above analysis of the six dimensions, it is clear that patient meets criteria for a 3.5 level of care for the period of time under consideration. Accordingly, the requested residential treatment center services provided during the period at issue were, and are, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were, and are, medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry, with subspecialty certification in addiction 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the BRCA gene test that was provided. The Health Plan has denied the service at issue as investigational for evaluation of the enrollees risk of breast cancer.Findings:  Two out of three physician reviewers found that the National Comprehensive Cancer Network (NCCN) guideline recommendation for genetic testing of BRCA genes in the case of a known familial mutation is to test the specific known familial mutation, not the entire BRCA1 gene and BRCA2 gene. The patients mother had BRCA1 positive breast cancer with a known mutation. Thus, a few nucleotide letters needed to be sequenced as opposed to more than one thousand. The BRCA 2 gene did not need to be sequenced, given the known family history of a mutation in the BRCA 1 gene. Thus, the BRCA gene test that was provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. One physician reviewer found that the patient was found to be BRCA1 positive with the pathogenic mutation that she inherited from her mother and the BRCA gene test that was provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapyFinal Result: The reviewers determined that the requested testing 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 reviewers 1 and 2 are board certified in medical genetics and genomics, physician reviewer 3 is board certified in clinical biochemical genetics and all 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

A 29-year-old female enrollee has requested pudendal nerve block for her endometriosis. Findings: The physician reviewer found that review of the relevant scientific literature reveals no valid studies to support the use of pudendal block for the treatment of chronic pain from endometriosis. The patients stage IV endometriosis was appropriately treated surgically, and as a result she should be expected to have significant chronic pain relief. Furthermore, there is no evidence the pudendal block was necessary to give immediate relief from postoperative pain.
Appeal type: Experimental/Investigational
Decision: Overturned

A 58-year-old female enrollee has requested for inhome hemodialysis for treatment of her chronic kidney disease, secondary hyperparathyroidism and hypertension. Findings:  Two physician reviewers found that home hemodialysis is usually performed at night five days a week.  This provides for an improved clearance as well as better control of hypertension, volume status and electrolytes.  This results in improved cardiovascular performance.  Nocturnal dialysis also allows patients to live an improved productive lifestyle, as they are not committed to a dialysis center three times a week. Finally, in-home dialysis generally results in a better performance status at time of consideration for transplant.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. Applying the American Society of Addiction Medicine (ASAM) criteria, the RTC services were not medically necessary for treatment of this patient. The ASAM criteria for level of placement can be applied to a patients presentation to help determine the appropriate level of care. According to the ASAM criteria, documentation should satisfy both dimension 1 to establish acute intoxication and/or withdrawal potential; and dimension 2: biomedical condition and complications. These criteria were not met, according to the patients presentation. The progress notes indicate that the patient was admitted with a history of polysubstance use as well as mood issues. The patient was not exhibiting any withdrawal symptoms during the disputed timeframe. The patient did not report any significant medical issues that were affecting treatment. Her vital signs were within normal range. The patient did not have any plan or intent of self-harm and did not engage in any self-harm behaviors during admission. The patient did not describe any suicidal thoughts or psychosis. The patient expressed motivation for treatment numerous occasions and had identified a sober living facility early in her treatment. The patient expressed a need for continued treatment and expressed an understanding of struggles with substance use and was insightful in therapy sessions. The progress notes do not reflect any aberrant behaviors of any type. The records indicate that the patients overall functioning was good. There was no indication of the problems with activities of daily living. The patient was not experiencing behavioral issues, aggression, or oppositional behaviors. Given these findings, the RTC services were not medically necessary for 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 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 one hour of speech therapy three times a week, one hour of occupational therapy three times a week, and one hour of physical therapy three times a week. The documentation does not support that this patient requires the skills of a qualified provider of speech, physical, and occupational therapy services. The documentation indicates that the patients functional status is at a baseline and has been chronic. The providers notes from speech, occupational, and physical therapy indicate that the patients functional level does not require skilled therapy services. The patient has maintained her level of mobility through daily active range of motion (AROM) and transfers. The patient has tube feedings and has not had an updated modified barium swallow study to assess if there has been a change in her swallowing status. Her chronic cognitive impairments prove to be a barrier in progressing as well, as they limit her ability to motor plan and sequence higher levels of mobility and self-care. She has maintained her current level of functional ability with minimal fluctuations. No further skilled inpatient speech, occupational, or physical therapy needs have been indicated per the medical progress notes. All told, the requested one hour of speech therapy three times a week, one hour of occupational therapy three times a week, and one hour of physical therapy three times a week, 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 physical medicine and rehabilitation with subspecialty certification in neuromuscular 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

A 41-year-old female enrollee requested authorization and coverage of multiple myomectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees uterine fibroids.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.