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

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) for evaluation of the enrollees right knee pain.  Findings: The physician reviewer found that the patient has been evaluated with two MRI exams and arthroscopy. The arthroscopy revealed degenerative changes and a stable root tear of the medical meniscus, which the provider noted is not amenable to arthroscopic repair. The patient has been told she does not need a follow-up MRI exam by the provider and there are no red flags to support an indication for follow-up imaging. All told, the requested MRI for further evaluation of this patients right knee pain is not supported as medically necessary.Final Result: The reviewer determined that the requested diagnostic procedure 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 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: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lyrica 200 mg. Cruccu notes that trigeminal neuralgia is characterized by recurrent brief episodes of unilateral electric shock-like pains, abrupt in onset and termination, in the distribution of one or more divisions of the trigeminal nerve root. The author notes that carbamazepine (brand name Tegretol) and oxcarbazepine (brand name Trileptal) are the recommended first choice for long-term treatment of trigeminal neuralgia. Bendsten and colleagues note that lamotrigine, gabapentin, botulinum toxin type A, pregabalin (brand name Lyrica), baclofen and phenytoin may be used either alone or as add-on therapy. When used as a third line agent, Lyrica is typically prescribed in an adjunctive role, to be taken daily, rather than as needed. In this case, the patient has diagnoses of trigeminal neuralgia and lumbar degenerative disc disease. While an undated letter from the provider reports that the patient is stable on Lyrica for their degenerative disc disease, notes reported that the patient was using Lyrica as needed to manage symptoms of trigeminal neuralgia. In this clinical setting, given the limited data in current medical literature supporting the use of Lyrica as needed for the treatment of trigeminal neuralgia, the requested medication is not medically indicated. Therefore, Lyrica 200 mg 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 neurology with sub-specialty certification in vascular 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: Medical Necessity
Decision: Overturned

The patient is a 37-year-old female with a body mass index (BMI) of 42. She has requested authorization for gastric bypass surgery. Based on the submitted information, it does not appear the patient has undergone a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery. The Health Plan indicates the requested procedure is not medically necessary for treatment of the patients medical condition.With a BMI of 42 the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese. However, although medically the patient meets criteria for weight loss surgery, she needs to undergo a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. If the evaluation indicates the patient is an appropriate candidate for weight loss surgery, the surgery should be authorized. If the evaluation indicates the patient is not an appropriate candidate for weight loss surgery, the surgery should not be authorized.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old male enrollee has requested authorization and coverage for Gralise.  Findings:  The physician reviewer found that the issue in this case is the approval of a novel delivery system of Gabapentin which is well established for the treatment of neuropathic pain and is a first line treatment agent listed in the EFNS guidelines and the most recently issued guidelines for neuropathic pain. Gralise is the exact same molecule as Gabapentin, only the bioavailability and dispersal systems are novel, which can have a huge impact on the efficacy of the medication as the absorptive properties and bioavailability can greatly influence adverse events and tolerability.  The original studies for Gralise are for patients with post-herpetic neuralgia, but this is also the case for all Gabapentin and this molecule is frequently used to treat all types of neuropathic pain. In this case, the patient has failed multiple neuropathic pain medication, injections and physical therapy. He has had at least 50% relief of his pain with Gralise trial. There is good evidence for the use of Gabapentin in neuropathic pain from all etiologies, including peripheral and central.  Therefore, based on lack of alternatives and taking into consideration the current standard of care for use of Gabapentin in neuropathic pain, the request for Gralise is appropriate and medically necessary. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old female enrollee requested continued acute inpatient psychiatric services provided for medical treatment of her behavioral health conditions.  Findings:  The physician reviewer found that considering the patients diagnoses, history and symptom burden upon presentation, treatment at the acute level of care was initially indicated.  However, the medical records do not support the medical necessity for continued inpatient care as the patient was complying with rules and structure.  Despite her anxiety and pain, she was not demonstrating any unsafe behavior.  The patient was independent in her activities of daily living.  The patients antidepressant medication was increased.  She had been stable on her other medicines, which included a second generation antipsychotic.  Subsequently, the patient had a brighter disposition with decreased paranoia and thought blocking.  She was not suicidal or homicidal.  The discharge plan focused on placement, and there were no changes to the treatment plan.  Although the patient had chronic symptomatologies consistent with a formal thought disorder, there was no evidence of an acute psychiatric syndrome.  The services being provided were no longer expected to significantly improve her condition or prevent a more serious episode of illness.  Her delusional complex and paranoia was not impairing her independent functionality, resulting in disruptive behavior or posing an imminent risk to the patient or others in the community.  All told, continued acute inpatient psychiatric services were not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old female enrollee has requested a whole body positron emission tomography (PET) scan for evaluation of her status post inflammatory breast cancer. Findings:  Two physician reviewers found that it is well documented in the peer-reviewed medical literature that PET scans can be beneficial for initial staging of patients with suspected metastatic breast cancer. Studies have also shown that PET scans can be of benefit in monitoring a patients response to chemotherapy. However, review of the peer-reviewed medical literature found no support for the use of PET imaging for surveillance purposes in patients with a history of inflammatory breast cancer. A study by Yang indicates that data for PET imaging in patients with inflammatory breast cancer are still preliminary and will require further studies for confirmation. Further, the National Comprehensive Cancer Network (NCCN) guidelines do not support the use of PET scans for surveillance of patients with a history of breast cancer and no clinical suspicion of recurrence. The PET scan performed was ordered as a surveillance study, as there was no clinical suspicion of recurrent carcinoma. In conclusion, the PET scan performed was not likely to be more beneficial for evaluation and treatment of the patients medical condition than any available standard imaging.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lyrica 50 mg capsules for treatment of the enrollees pain. Findings: The physician reviewer found that Lyrica has well-documented efficacy and safety for treating neuropathic pain, which is what the patient is describing.  She had significant side effects from a trial of gabapentin and does not have an indication for a trial of duloxetine. The medical evidence supports the requested medication in this clinical setting. 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 anesthesiology with sub-specialty certification in pain 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: Urgent Care
Decision: Upheld

A 55-year-old male enrollee has requested air ambulance transport services for evaluation of his medical condition. Findings:  The physician reviewer found that upon review of the submitted documentation, a prudent layperson would not have reasonably believed that the air ambulance transport services were urgently needed services. The patient was stabilized in a regional level III trauma center on the date of injury. Appropriate surgical treatment was available at this facility and follow-up care could have been coordinated. While the patient notes concerns about his aftercare, the evidence provided does not demonstrate that the patients health was likely to seriously deteriorate if he remained in the facility for treatment rather than returning to the state indicated so that he could be discharged to his home following surgery. Therefore, the air ambulance transport services were not urgently needed services.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz 5 mg, twice a day for the treatment of the enrollees rheumatoid arthritis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The current medical evidence supports a trial and failure of full dose disease modifying anti-rheumatic drug (DMARD) therapy and then anti-tumor necrosis factor therapy prior to the use of Xeljanz. In this patients case, the records do not document that she has failed an adequate trial of methotrexate at full dose alone or in combination with Plaquenil, sulfasalazine or other DMARDs. Additionally, despite the potential hepatic toxicity with methotrexate, the records do not document that the patient has risk factors outside of the norm for methotrexate-related hepatotoxicity. The patient also does not have specific documented risk factors for coccidioidomycosis limiting her ability to take an anti-tumor necrosis factor agent if she fails or does not tolerate methotrexate. Per American College of Rheumatology guidelines, after the failure of DMARD therapy alone or in combination, the recommendation is to add or use an anti-tumor necrosis factor agent or biologic agent, such as Enbrel or Humira, prior to Xeljanz. There is a lack of support for the requested medication in this clinical setting. All told, Xeljanz 5 mg, twice a day 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

A 43-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees obesity.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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old male enrollee has requested an evaluation for a stem cell transplant for the treatment of his neuromyelitis optica. Findings:  Three physician reviewers found that this patient has been diagnosed with neuromyelitis optica that has been treated with a variety of medications, without control. Neuromyelitis optica is a demyelinative disorder and is often treated with steroids, plasmapheresis and azothiaprine. Evaluation for stem cell transplantation has been suggested. A literature review yields no data regarding treatment of neuromyelitis optica with stem cell transplantation. Review of the literature regarding the treatment of multiple sclerosis with adult stem cell therapy (ASCT) does not confirm clinical efficacy beyond standard therapeutics. Potential complications of ASCT are noted to include opportunistic infection, neoplasm and death. There is insufficient evidence that the suggested therapy is likely to be more effective for this patient than standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 8-year-old female enrollee has requested occupational therapy (OT) including sensory integration therapy (SIT) for treatment of the enrollees autism and that the enrollees OT therapist be a sensory integration praxis test/sensory integration certified occupational therapist.  Findings:  The physician reviewer found that Sensory integration therapy (SIT) is a useful part of the OT therapeutic approach to improve the function of patients with autism. Roberts and colleagues describe improvement of behavior patterns in children who have been treated with OT utilizing sensory integration techniques. Based upon the patients treatment history and current presentation, OT is medically reasonable and necessary to include SIT. The request for the patients occupational therapist to be a sensory integration praxis test/sensory integration certified occupational therapist is not medically necessary. An appropriately trained pediatric occupational therapist is capable of delivering this service. Therefore, based upon the medical literature cited above and the clinical documentation submitted, a portion of the requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female enrollee requested gastric sleeve revision to gastric bypass for treatment of her obesity, sleep apnea, dilated cardiomyopathy, asthma, and chronic obstructive pulmonary disease.  Findings:  The physician reviewer found that the patient has undergone two previous bariatric surgical procedures that have both failed from a weight loss perspective. She is now seeking a third bariatric surgical procedure for persistent morbid obesity. There is published literature to suggest that the potential complication rate is higher with repeat procedures (Coblijn, et al). Without a thorough assessment by a multidisciplinary team including a dietician and a health psychologist, and without evidence of compliance with an exercise regimen including recommended eating behaviors, it is likely the patient will experience a poor weight loss outcome once again. In the absence of a clinical indication or evidence-based rationale for the requested surgery, this patient should undergo counseling, education, and non-surgical weight management for treatment of her continued obesity. Thus, the requested gastric sleeve revision to gastric bypass surgery is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

 A female enrollee requested a computed tomography (CT) scan of the thoracic spine and a CT scan of the lumbar spine without contrast for medical evaluation of her back pain.  Findings:  The physician reviewer found that in this patients case, the standard of care is plain film x-rays, particularly in the absence of trauma and neurological deficits. The medical records do not indicate any trauma or neurological deficits. Furthermore, the patient did not have a six-week trial of conservative management prior to the CT scans of the spine, which is discordant with the imaging guidelines and accepted standards of care in medical practice. Therefore, the medical necessity of the services at issue has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old male enrollee has requested for proton beam therapy for treatment of his prostate cancer. Findings:  The physician reviewer found that IMRT, Image Guided Radiation Therapy (IGRT) and proton beam therapy are equivalent as to their approach in controlling cancer. Neither one has been shown to have survival benefit over the others. No clinical trials data are published as of now. Any of these modalities is equivalent in effectiveness and side effects for this patients prostate cancer.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for psychiatric emergency medical service. Findings:  The physician reviewer found that the medical services provided were not necessary for treatment of a psychiatric emergency medical condition. On admission the patient was not a danger to self or others, and was not gravely disabled. The patient showed no self-harming behavior. The patient had no auditory hallucinations, visual hallucinations, delusions, or mania. The patient had no comorbid medical conditions, and the seizure experienced was 10 years prior to admission.  The patients vital signs were stable and the patient was not in an altered state of consciousness. The patients CIWA of 13 indicates moderate level of withdrawals, and does not constitute a life threatening condition. The patient was placed on a Valium protocol, which is commonly done in an ambulatory setting. The patient did not have a psychiatric emergency medical condition during the dates in dispute. For the reasons provided, the patient did not receive psychiatric emergency medical services on the dates of service at issue. Final Result: The reviewer determined that the patient did not receive psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a subcutaneous implantable cardioverter defibrillator (S-ICD) for treatment of his medical condition. Findings:  Three physician reviewers found that the current medical evidence supports the requested services in this clinical setting.  In this circumstance of short QT syndrome, syncope, and a family history of sudden cardiac arrest, defibrillator placement is appropriate.  Both traditional endocardial lead systems and subcutaneous systems accurately detect ventricular arrhythmias.  However, placement of a subcutaneous defibrillator has potential long-term advantages in this particular circumstance.  For this patient who will likely require a defibrillator for many decades, the risk of lead failure and lead extraction, which are associated with significant morbidity and mortality, are higher when implanted with a traditional endocardial lead device.  Subcutaneous leads are not subject to the stresses of the cardiac contraction and so should be less likely to fail or need replacement.  Also, if lead failure were to occur, then the subcutaneous lead should be easier to access and extract with lower risk of morbidity.  Therefore, the requested subcutaneous implantable cardioverter defibrillator is likely to be of greater benefit than other treatment options.  Final Result: Three 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:   All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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.that