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

The patient is a 39-year-old female who started having persistent headaches in September 2003. The headaches are temporal and frontal in location, more so on the left than the right. The patient was evaluated by a neurologist and has been followed on a regular basis. Records indicate a normal neurological exam. The patient has undergone several tests including temporal artery biopsy, CT scan of the brain, MRI of the brain, MRA of the neck and brain, EEG, and lumbar puncture. All of these tests were within normal limits. The patient has been treated with several different medications with transient or no improvement in her headaches. The patients neurologist has requested an MRI of the cervical spine. The Health Plan has denied this request.The patients records provide no basis for the necessity of an MRI of the cervical spine. No history, signs or symptoms are documented indicating that a structural abnormality of the cervical spine may be the cause of the patients headaches. There is no documentation that the patient has undergone radiographs of the cervical spine. The Health Plan is correct, there is insufficient evidence to demonstrate the requested MRI is medically necessary. Therefore, I have determined the requested MRI is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee requested 120 tablets of buprenorphine-naloxone 8 mg, four times per day (120 tablets for 30 days) for medical treatment of her complex chronic pain syndrome.  Findings:  The physician reviewer found that the request for 120 tablets of buprenorphine-naloxone 8 mg, four times per day (120 tablets for 30 days) was not and is not medically necessary. Suboxone is U.S. Food and Drug Administration (FDA) approved for opioid dependence at a recommended maximum dose of 24 mg per day. In this case, the patient has chronic pain and Suboxone is not FDA-approved for chronic pain. Furthermore, Baron and McDonald reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. Based on the documentation submitted for review and the peer-reviewed literature cited above, the medication quantity at issue was not and is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for admission into an alcohol detoxification facility. Based on the available documentation, this patient meets the American Society of Addiction Medicine (ASAM) criteria for admission into an alcohol detoxification facility. Overall, the patient is medically unstable. Overall, this patients presentation supports inpatient detoxification and related services. Given the severity of the patients illness and his history of relapses, admission into an alcohol detoxification facility is in accordance with generally accepted standards of medical practice and is therefore medically necessary. 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 psychiatry with expertise in addiction 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 Zepatier 50/100 mg one tablet daily for 12 weeks.  Findings:  The physician reviewer found that according to the most recent 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 limited life expectancy due to non-liver-related conditions), regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 50/100 mg one tablet daily for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 35-year-old male enrollee has requested psychiatric residential treatment center (RTC) services for the treatment of his opioid dependence and obsessive compulsive disorder.  Findings:  The physician reviewer found thatresidential treatment was not medically necessary based on the patients documented level of functioning. The patient no longer needed 24-hour supervision and could safely have been treated on an outpatient basis. The documentation suggests the patients condition improved, that he was better able to control his behaviors, and he was learning to handle stressors.  Medical records state that there was no suicidal or homicidal ideation and no hallucinations or delusions. All told, the RTC services were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Criteria/Case Nature of Statutory Summary: An enrollee has requested a wearable cardiac defibrillator (Zoll LifeVest) for treatment of her medical condition. Findings:  The physician reviewer found that based on the records provided, this patient had a newly recognized cardiomyopathy for which medical therapy was initiated.  In this circumstance, there is potential for recovery of left ventricular function over time with medical therapy and there was no indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest.  Placement of a prophylactic defibrillator is not recommended until a period of time greater than 90 days where continued left ventricular dysfunction (ejection fraction less than or equal to 35%) is documented to persist in spite of appropriate treatment.  A prophylactic defibrillator before this time has not been demonstrated to improve outcome.  All told, the wearable cardiac defibrillator provided was not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the device 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 internal medicine with sub-specialty certification in cardiovascular disease 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 genetic tests. Findings:  Three physician reviewers found that the patients provider recommended and ordered genetic tests to evaluate which medications were best suited for treatment of this patient. In the records provided, this patient was diagnosed with obsessive compulsive disorder and depression. The patients provider had ordered genetic tests (GeneSight Psychotropic assay) to determine the effectiveness of the patients treatment. However, there is limited clinical evidenced-based data that support the use of genetic tests such as the GeneSight Psychotropic assay for the evaluation of patients diagnosed with obsessive compulsive disorder. Medical studies are lacking to support the effectiveness of these tests over other modalities in guiding treatment for this patients medical condition. Final Result: Three 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: All three physician reviewers are board certified in psychiatry 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: Overturned

A 57-year-old male enrollee has requested Mist Therapy System (low frequency, non-contact, non-thermal, ultrasound therapy) for treatment of his peripheral T-Cell lymphoma.  Findings:  Three physician reviewers found that this patient has developed significant infections due to skin wounds, ultimately requiring amputation of his leg secondary to osteomyelitis. He has had multiple treatments with ultrasound for his scalp, showing impressive improvement in wound healing. In the peer-reviewed medical literature, there are multiple studies showing that non-contact ultrasound therapy is effective in hastening the healing of wounds (Kavros, et al). Non-contact ultrasound therapy has also been demonstrated to result in improved health outcomes in patients with diabetic ulcers in a randomized, double-blind controlled multicenter trial (Ennis, et al). Ennis and colleagues reported a wound healing rate of 40% in ultrasound treated wounds versus 14% in placebo.  Additionally, there is scientific data to show that ultrasound therapy of wound fibroblasts have changes at the cellular level that would promote faster healing through activation of signaling pathways that increase numbers of keratinocytes (skin cells) to fill in the wounds (Lai and Pittelkow). This patient has shown excellent improvement with the MIST therapy modality to promote healing of his recalcitrant wounds. Further, use of this device is supported with good evidence in the medical literature that it can be effective in wound healing. Consistent with these findings, the requested MIST system should be approved as it is likely to be more beneficial for this patient than other standard therapies.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her breast cancer in the right breast. Three physician reviewers found that in the medical literature, Skaane and colleagues reported that the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, the literature does support the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate when used with standard mammographic imaging. Given these findings, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the services at issue were 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 61-year-old female enrollee has requested Synvisc injections for treatment of her right knee osteoarthritis. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested therapy. There is a lack of adequate randomized, controlled studies demonstrating the clinical effect from Synvisc, also called hyaluronan injections. There is a recognized and documented incidence of aseptic inflammatory reactions due to allergic response. In this case the patient has had previous Synvisc injections and with each injection and each exposure to the antigen, there is an increased risk of allergic response. There is also a low but present risk of iatrogenic infection within the joint. Rutjes and colleagues assessed the efficacy of viscosupplementation for adults with symptomatic knee osteoarthritis. This study concluded after review of a total of 89 trials involving 12,667 adults that in patients with knee osteoarthritis viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects (Rutjes et al). Moreover, the American Academy of Orthopaedic Surgeons practice guidelines for the treatment of osteoarthritis of the knee states, We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. Finally, several studies evaluating repeated treatment protocols document adverse events including inflammatory changes within the knee joint and in some cases requiring arthrocentesis after multiple injections. Given the reasons provided, the requested therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer.   Findings:  The 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 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: All three 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: Physician reviewers number one, two, and three are board certified in diagnostic radiology and 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 42-year-old female enrollee requested authorization and coverage for a pulmonary function test for the treatment of asthma.  The health plan has denied this request indicating that the requested test is not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested pulmonary function test is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Emgality 120 mg/mL injection pens - two injection pens for the first dose (loading dose), and then one injection pen once monthly for maintenance dose. Findings:  The physician reviewer found that Migraine is an episodic disorder, the centerpiece of which is a severe headache generally associated with nausea and/or light and sound sensitivity. Emgality is a calcitonin gene-related peptide (CGRP) antagonist that has been shown to be effective in preventative migraine management and is approved by the U.S. Food and Drug Administration for migraine prophylaxis. Additionally, concurrent Botox therapy is not a contraindication to Emgality and a case can be made of improved therapeutic effects when on both a CGRP antagonist and Botox. In this case, the patient has tried and failed multiple alternative medications. Additionally, the patient is on Botox therapy. Therefore, Emgality 120mg/mL injection pens - two injection pens for the first dose (loading dose), and then one injection pen once monthly for maintenance dose are medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology 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: Urgent Care
Decision: Upheld

A 43-year-old female enrollee has requested emergency services for evaluation of her abdominal pain, nausea and vomiting.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date and time in question. In this case, the patient presented with abdominal pain, vomiting, and diarrhea. She had already been evaluated at another emergency department for these same symptoms and had been discharged from the other facility after receiving medical treatment. There is nothing in the record to suggest that the patient had experienced any sudden or acute worsening of her symptoms in the prior amount of time that would lead a prudent layperson to believe their health to be in imminent danger. This patients pain was chronic, not acute. There was no sudden deterioration in her physical condition to justify a second emergency visit on that date. In sum, the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services provided. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees alcohol dependence, stimulant dependence, major depressive disorder, anxiety, and other psychoactive substance abuse. At issue in this case is whether the requested residential treatment center services provided are medically necessary for treatment of the enrollees behavioral health condition.The American Psychiatric Association treatment guidelines for substance use disorders recommends that residential treatment or similar care higher than outpatient is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance uselack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. A patient requires safe and stable living environments in order to develop their recovery skills thus qualifying for ASAM Level III treatment at least i.e. residential or inpatient treatment similar to what the patient received at the facility. Patients conditions wax and wane. A relatively positive documentation by one person on one day does not indicate spontaneous cure or that the patient is in the clear, it simply denotes progress and that treatment is working, which is an indication to continue not cease treatment. The purpose of detoxification is to make the patient physically stable and safe. Rehabilitation is the essential component that should follow detoxification to help the patient maintain sobriety and reduce risk of relapse. Given the severity of the patients illness including the behaviors that put himself and others at risk as well as an unhealthy home environment, residential treatment was in accordance with generally accepted standards of medical practice; clinically appropriate for the patient's illness, and is therefore medically necessary.Final Result: The reviewer determined that the requested services 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 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.