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

A 26-year-old female enrollee has requested reimbursement for residential treatment services for treatment of chemical dependency.  Findings:  The physician reviewer found that the patient had no acute signs of withdrawal when she was admitted to the residential treatment facility and there were no serious medical, emotional or behavioral conditions that required 24-hour monitoring or supervision. Although she had a significant history of polysubstance abuse/dependence, there is no evidence she required on-going residential treatment. The patient could have been appropriately treated at a lower level of care such as chemical dependency program supervised by a psychiatrist.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested for breast tomosynthesis for breast cancer screening.  Findings: Two reviewers found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. For these reasons,  breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.  Final Result: Two 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 physician reviewers are 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Tylenol No.4 and morphine 3 times per day for treatment of the enrollees medical condition.  Findings: The physician reviewer found that based on the documentation submitted for review, Tylenol No.4 and morphine have not been established as medically necessary for treatment of the patients medical condition. Review found the provider recommends trigger point injections. Trigger point injections address hyperirritability in the muscle, that when compressed, is locally tender, and if sensitized, gives rise to referred pain and tenderness. In addition, there are many physical therapies that are used in the management of myofascial pain and the majority involves the application of pressure or stretch or both at the relevant myofascial trigger points. In this case, there is a lack of documentation demonstrating that the patient has trialed non-opioid medications, such as muscle relaxants. In addition, the providers recommendation for trigger point injections is medically reasonable and appropriate in this clinical setting. Given the above, the requested medications are not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medications 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing. Findings:  Two of the three physician reviewers found that the submitted documentation supports a portion of the services at issue. The American College of Obstetricians and Gynecologists recommends that screening for spinal muscular atrophy and cystic fibrosis should be offered to all women who are considering pregnancy or are currently pregnant. However, screening for Fragile X syndrome is not recommended for all pregnant women. Screening for Fragile X syndrome is not common practice due, in part, to the difficulty in predicting phenotype in offspring of low-risk women (women with a negative personal and family history) with a premutation. Therefore, spinal muscular atrophy carrier screening and cystic fibrosis screening were likely to have been of greater benefit than other methods of evaluating this patient. However, the superior efficacy of Fragile X screening has not been established. Final Result: The reviewers determined that a portion of the services 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 partially overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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

An enrollee has requested pelvic floor electrical stimulation for treatment of her urinary incontinence.  Nature of Statutory Criteria/Case Summary:  Three physician reviewers found that the requested services are not likely to be more effective for this patient than other available options. This patient presents with symptoms of mixed incontinence of moderate severity with evidence of pelvic floor muscle laxity. A review of the medical literature suggests that in patients that have tried and failed pelvic floor training and weight loss in addition to medications, there is an indeterminate but possible benefit to non-implanted electrical stimulation if biofeedback has also failed. In this case, there is no documentation of weight loss consultation or medication use and the requested services would not likely prove more beneficial than standard therapies. For the reasons provided, pelvic floor electrical stimulation is not likely to be more beneficial than standard medical therapy in this clinical setting. Final Result:  Three 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: All three reviewers are board certified in urology 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

Nature of Statutory Criteria/Case Summary: The patient visited her podiatrist complaining of bilateral heel pain. Prior treatment has included three corticosteroid injections to the right heel, two injections to the left heel, meloxicam, weight loss, icing, and post exercise stretching. On physical examination, pain is noted upon palpation to the plantar medial heels bilaterally. Her diagnosis includes plantar fasciitis, recalcitrant. The provider recommended the patient continue icing, begin diclofenac daily, and continue Superfeet over-the-counter arch support orthotics. The patient reported improved pain. The patient is exercising and has lost 10 pounds, and continues to ice and stretch daily. The patient continues to exhibit pain to the medial calcaneal tubercle bilateral heels. The treatment plan included custom molded foot orthotics.The progress notes advised that patient has tried and failed numerous conservative treatments for bilateral heel pain. These treatments include oral and topical non-steroidal anti-inflammatory drugs (NSAIDs), local corticosteroid injections, stretching, icing, weight loss, and Superfeet over- the-counter arch supports. Custom molded foot orthotics are a mainstay in the treatment of plantar fasciitis. Studies advise that certain foot structures will respond better to a custom molded insert and allow for dramatic healing of plantar fasciitis. Therefore, the requested custom molded foot orthotics that were provided were medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is doctor of podiatry, 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 female enrollee requested authorization and coverage to remain on the liver transplant list. The Health Plan terminated the enrollee from the liver transplant list indicating that the liver transplant is not medically necessary due to the enrollees non-compliance with the Health Plans transplant requirements.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that it is not medically necessary for the enrollee to remain on the transplant list at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee has requested Norco 10mg (3 times per day as needed) and Soma 350mg (3 weeks on and 1 week off as needed) for treatment of his chronic pain syndrome.   Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medications. The clinical documentation lacked evidence of a thorough physical exam of the patient, documentation of the patients average rate of pain on a visual analog scale (VAS) and documentation of other conservative treatment modalities the patient has utilized for his pain complaints. The clinical notes also evidence the patient was advised to utilize active treatment modalities for his pain complaints, which the patient declined. Standard of care would indicate the patients medication regimen is not supported at this time as there is lack of documentation evidencing efficacy of the patients medication regimen, such as a decrease in rate of pain on a VAS, increase in objective functional improvement, and utilization of active treatment modalities. Given the reasons provided above, the requested medications are not medically necessary for the treatment of the patients chronic pain syndrome.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for air ambulance transport services provided from California to Illinois for treatment of the enrollees traumatic brain injury following a high speed motor vehicle collision.  Findings:  The physician reviewer found the air ambulance transport services were medically necessary for treatment of the patients medical condition.  Medical monitoring can minimize health risks during air travel and timely rehabilitation can improve functional outcomes. In this case, the patient sustained a brain injury and multiple fractures. Due to her brain injury and orthopedic injuries, monitoring during air travel with air ambulance transport services was medically necessary. Moreover, early specialized rehabilitation with her support network was clinically indicated. As such, air ambulance transport services provided from California to Illinois were medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the contrast-enhanced cardiac computed tomography (CT) angiographies for evaluation of the enrollees hyperlipidemia. Findings:  Two physician reviewers found that the contrast-enhanced cardiac computed tomography (CT) angiography was not supported as likely to be more beneficial than standard risk assessment to determine this patients calcium score. The diagnostic procedure is a screening test that has not been demonstrated to provide improved health outcomes when used on a routine basis. This patient was found to have a score of 826, which placed the patient in a higher risk group. Once the patient was found to have a high calcium score, a stress test was indicated for further evaluation. However, the use of a cardiac CT angiography  was reasonable for further evaluation in lieu of the stress test. The sensitivity and specificity of cardiac CT angiography is similar to other non-invasive tests and obviates the need for a more invasive procedures such as cardiac catheterization. For these reasons, the calcium score was not likely to be more beneficial for evaluation of this patients medical condition than standard testing, but the cardiac CT angiography was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that a portion of 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 partially overturned.  Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 31-year-old female enrollee requested authorization and coverage of enrollment in a clinical trial involving autologous stem cell transplantation. The Health Plan denied the request indicating that the proposed trial is considered experimental for treatment of the enrollees systemic lupus erythematosus (SLE).Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old male enrollee has requested authorization and coverage for stereotactic body radiation treatment (SBRT). The Health Plan has denied this request indicating that the requested therapy is considered investigational for treatment of the enrollees prostate cancer.  Findings:  Three physician reviewers found that the patient presented with rising PSA. The patient underwent a prostate biopsy, which established a diagnosis adenocarcinoma of the prostate, with a Gleason score of six. The patient was offered several treatment options and stereotactic body radiation therapy (SBRT) treatment was discussed. The patient requested authorization and coverage for SBRT. The Health Plan has denied coverage of SBRT on the basis that it is considered experimental/investigational.This patient has early stage localized prostate cancer. He can be treated with several standard options of treatments including surgery, 3D conformal radiation therapy, intensity-modulated radiation therapy (IMRT) or brachytherapy. All these options are listed in the current National Comprehensive Cancer Networks (NCCN) guidelines. SBRT is an emerging technology which has been used in the last few years to treat several malignancies including prostate cancer. Currently, there are only a few publications in the peer-reviewed literature examining the role of SBRT in prostate cancer. These published studies are single institution studies with a small number of patients and short follow up. There are no large scale studies published supporting the efficacy and safety of SBRT with long term follow up. At the  present time, there are three phase II trials being conducted to evaluate the role of SBRT for prostate cancer. Until the results of such large scale trials are available, SBRT is still considered to be of unproven efficacy in this setting. Additionally, the NCCN guidelines for prostate cancer do not consider SBRT an accepted treatment for prostate cancer. Thus, SBRT is not likely to be more beneficial for this patient than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 46-year-old male who is a C4-5 quadriplegic. Since his injury he has had several electric wheelchairs. Approximately five years ago he required surgery for a decubitus ulcer and was provided a power wheelchair with power tilt to allow for pressure relief. The patient is seeking authorization for a standing power wheelchair. The Health Plan has denied this request.Since the patients surgery noted above there is no record of the patient having further skin difficulties. In September 2003, the patients durable medical equipment provider noted the patients current power wheelchair did not need to be replaced. In addition, the records submitted do not provide any evidence of the patients current equipment requiring replacement because of mechanical issues. Furthermore, the patients current wheelchair is appropriately equipped to meet the patients pressure relief needs. Based upon this information, there is no evidence demonstrating the requested equipment is medically necessary. Therefore, I have determined the Health Plans denial should be upheld
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Findings:  The physician reviewer found that the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. The patient has a composite score of 10. This score correlates with treatment in a community-based outpatient clinic setting such as outpatient treatment. Therefore, the RTC services provided were not and are not medically necessary for treatment of this patient. 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 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

A 45-year-old male enrollee has requested computed tomographic angiography (CTA) for an evaluation of his chest pain. Findings:  Three physician reviewers found that there are guidelines published from the American College of Cardiology regarding the appropriate use of cardiac CTA. CTA was not medically indicated for this patient, as CTA has not been recommended as a confirmatory step after negative stress testing. Available standard therapy would have been to evaluate the patient for atypical non-cardiac chest pain and medically treat the patient's risk factors/abnormal lipids. Cardiac catheterization would only be considered if the suspicion for significant coronary artery disease was truly high despite prior negative perfusion testing.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a six-year-old female enrollee has requested biofeedback services for the treatment of the enrollees autism. Findings:  Three physician reviewers found that while biofeedback therapy shows some promise for treatment of patients on the autism spectrum, adequate outcome data is lacking at this time. Most studies that have been performed have involved patients with attention deficit/hyperactivity disorder and have been short-term, and were not blinded or randomized. Larger scale outcome studies need to be performed before biofeedback can be considered to be beneficial. Presently, there is insufficient evidence to be able to conclude that biofeedback therapy represents a superior modality of treatment than the standard modalities that are available for the treatment of autism.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings: Three physician reviewers found that the medical evidence supports the services at issue in this patients case.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in patients with dense tissue.  This technique often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies, decrease in callbacks and increase in detection of small cancers.  Thus, it is likely the addition of breast tomosynthesis to the usual two protocol was more beneficial to the patient than had the examination been done with two-dimensional technique alone.  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 physician 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.