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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bidet. Findings:  The physician reviewer found that while hygiene is an important part of the management of PI, there are several options for local care. These options include a sitz bath, a standard or handheld shower head, or even a plastic squeeze bottle, and a hair dryer for drying the area afterwards. There are multiple different topical agents and medical therapies directed at the management of this problem. However, identification of the underlying etiology is also of importance. In patients following this sort of surgery, diarrhea or loose stool is very common. In addition, the more caustic nature of the small bowel contents passing through the anal canal increases the risk of PI. Therefore, dietary management and use of antidiarrheals, as well as local skin protections are as important as hygiene. Therefore, while a bidet is an alternative for use after bowel movement, there are other viable alternatives available for use. For these reasons, the requested bidet is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment 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 rectal surgery 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: The patient has requested authorization and coverage for authorization and coverage for Actemra (subcutaneous). The National Comprehensive Cancer Network (NCCN) has published extensive analysis on the management of immunotherapy related toxicities. Medical literature note that some immunotherapies are associated with unique toxicities of cytokine release syndrome (CRS) and neurologic toxicity and that the assessment and grading of these toxicities vary considerably across clinical trials and across institutions, making it difficult to compare the safety of different products and hindering the ability to develop optimal strategies for management of these toxicities. Medical literature note that tocilizumab may be a therapeutic option for the management of steroid refractory immune related adverse events secondary to immune checkpoint blockade. In this case, the patient has been diagnosed with CRS secondary to dual immune checkpoint blockade. In this clinical setting, while the NCCN guidelines support the use of intravenous tocilizumab, the use of subcutaneous tocilizumab is not discussed. Therefore, intravenous Actemra is medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certifications in medical oncology and in hematology 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 53-year-old female enrollee requested authorization and coverage of a gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 54-year-old female with a long-standing history of diet pill dependence as well as what has been identified as an eating disorder due to long-standing binging on high-caloric foods such as pasta, pizza, and ice cream, though devoid of purging of any sort. By the point of her most recent inpatient admission, she was using up to 35 diet pills per day. Her past history was also notable for periods of depression and frank paranoia, the latter having been attributed to her use of the diet pills, including her feeling that she could read others thoughts and predict the future. She was admitted for inpatient treatment some seven weeks prior due to the psychotic symptoms but soon returned to use of the diet pills. The patient had also had a history of seven inpatient hospitalizations, having been considered as increasingly agitated and psychotic by friends and family as early as October 2003. Her most recent admission diagnoses included: Eating Disorder  not otherwise specified, Major Depressive Disorder, recurrent, and Amphetamine Abuse.  Chart notes from her inpatient treatment reveal the patient as often quite agitated, intrusive, hyperverbal, affectively incongruent, labile, and given to oddities such as constant humming or knitting. She was felt to be frankly disorganized and was also treated with a variety of medications including Seroquel, topiramate, and Prozac. Earlier trials of Ritalin and Strattera were abandoned. The patient was also found to be lacking in insight. Ultimately, she made what was considered enough progress to allow for her exit from the hospital in April 2006, having been admitted in March 2006.  Discharge diagnoses were those of Eating Disorder  not otherwise specified, Major Depressive Disorder, recurrent, and Amphetamine Abuse, with a deferral on Axis II.  The patient was discharged on Prozac 30 mg, Seroquel 25 mg, and Topamax 200 mg.At issue is whether acute inpatient hospitalization was medically necessary for treatment of the patients condition.Based on the patients premorbid history as well as the chart notes documenting her treatment in the hospital, there was ample reason for her to be hospitalized. One issue had to do with her constant use of amphetamines, which was likely either compounding or leading to psychosis and affective cycling. In regards to the latter, there is also much documentation pointing to either a prima facie or secondary Bipolar Disorder. The patient was quite labile and thought disordered. Whether one agrees or not with Topamax and Prozac as the most optimal treatments for her illnesses, it is apparent the patient was quite ill. Nowhere is there documentation speaking to a particularly healthy degree of mentation, though she did improve to some extent by the end of her hospitalization. All told, I find that acute inpatient hospitalization was medically indicated and necessary. Accordingly, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested gene testing (molecular profiling) for the evaluation her medical condition.  Findings:  Three physician reviewers found that according to the documentation submitted for review, relapse was not identified and the patient currently has no evidence of disease. The timing of the molecular profiling was premature without any evidence for disease relapse. Furthermore, if the patient had relapsed disease, profiling of tissue from years ago would not have helped direct targeted therapy of the relapse. In sum, the relapsed lymphoma tissue would have been the one to analyze since new mutations could have been accumulated since autologous hematopoietic stem cell transplant previously.  All told, the services at issue were not 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 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 reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 34-year-old male enrollee requested authorization and coverage of continued treatment with the medication Serostim. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees HIV wasting syndrome.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 29-year-old female enrollee has requested substance abuse residential treatment center (RTC) for treatment of her alcohol dependence.   Findings:  The physician reviewer found that the residential treatment center (RTC) services provided from the time period specified were not medically necessary for treatment of the patients medical condition. Although the admission assessment noted that the patient reported withdrawal symptoms of shakes and sweats, there is no thorough evaluation of this description other than what was briefly mentioned in the admission assessment. Moreover, the documentation submitted for review fails to indicate vital signs, Clinical Institute Withdrawal Assessment (CIWA) scales and a psychiatric evaluation. The patients comorbid biomedical conditions of seizure disorder and psychiatric conditions of depression were controlled on medication and were not of a severity that required 24-hour supervision in a residential setting. She denied suicidal ideation and she was not a danger to herself or others.  She was described as motivated, and was actively engaged in treatment as documented in her counselors notes. While she had the potential for relapse, she demonstrated recognition and insight into her triggers and had formulated a plan of prevention. Although she did not plan to have substantial contact with her family, she was discharged to sober living and planned to attend meetings. Finally, the patient did not show acute psychiatric or medical symptoms that would interfere with her maintaining abstinence and recovery outside of a 24-hour structured setting. She did not show self injurious or dangerous behavior towards self or others. She showed no major functional impairment. Given all of the above, her condition did not meet the medical necessity criteria for residential level of care and could have safely been treated at an outpatient level of care along with community based resources such as 12-step programs. Based on the medical literature cited above and the documentation submitted for review, the RTC level of care provided from the time period specified were not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for hypnotherapy services. Currently, hypnotherapy is not recommended for the treatment of patients with bipolar disorder and/or insomnia. Small observational studies have reported that hypnotherapy may increase slow wave sleep. However, the available evidence for hypnotherapy is limited primarily because of the small number of studies and low methodological quality of the included studies. Overall, there is a lack of robust and well controlled studies to support the utility of hypnotherapy for insomnia. Chamine and colleagues evaluated the available studies using hypnotherapy for the treatment of patients with sleep problems and other comorbid conditions with sleep problems. The authors found that, The current evidence is limited because of few studies assessing populations with sleep complaints, small samples, and low methodological quality of the included studies. Similarly, Lam and colleagues reported that additional studies are needed to include larger sample sizes as well as improved study designs and methodologies. For these reasons, the requested hypnotherapy services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the requested hypnotherapy services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for Developmental Individual-Difference Relationship (DIR)/Floortime provided for treatment of the enrollees autism.Findings:  The physician reviewer found that there is a lack of peer-reviewed literature supporting the services at issue as medically necessary for treatment of the patients medical condition. There is some medical literature demonstrating that the DIR/Floortime model improves functional development levels and Childhood Autism Rating Scale (CARS) scores in children with autism. However, the data in support of DIR/Floortime is mostly pilot studies with a minimal number of participants. There is sufficient support in the peer-reviewed literature demonstrating that evidence-based ABA therapy is effective for the treatment of patients with autism. All told, the DIR/Floortime provided from March 2015 through December 2015 was not medically necessary for treatment of the patients medical condition. Final Result: The reviewers 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 physician reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 uvulectomy. On review of this patients records, there is a lack of clinical documentation that other common potential causes of chronic cough, throat clearing, dysphagia, and hoarseness had been ruled out, such as asthma and gastroesophageal reflux disease (GERD). Asthma and GERD are among the most common etiologies of chronic cough. Current medical literature reports do not recommend consideration of modified uvulopalatoplasty until common causes had been ruled out. Additionally, while clinical documentation reported uvular hypertrophy or elongation, there is a lack of evidence that laryngoscopy was performed, which would be helpful in potentially identifying other potential causes of the patients symptoms. Moreover, the records do not indicate that the patients uvula is touching the surface of the epiglottis, which has been shown to trigger cough reflex. For these reasons, the requested uvulectomy is not medically necessary for 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 otolaryngology 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 42-year-old female enrollee has requested a consultation with a rheumatologist for evaluation of her medical condition.   Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested service. First, ANA testing is not sufficient to establish or refute the diagnosis of lupus or other autoimmune diseases (Peng and Craft). The laboratory method by which the ANA result was obtained is not specified in the medical records. The standard for antinuclear antibody testing is the fluorescent ANA test. However, many laboratories currently use an enzyme-linked immunosorbent assay (ELISA) which is less sensitive than the fluorescent test (Meroni and Schur). The result of a negative ELISA does not rule out the diagnosis of lupus. Second, the patient is complaining of pain, dry eyes, and numbness of the hands and the records show that she was diagnosed with lupus and fibromyalgia in the past. For the reasons provided above, the requested consultation with a rheumatologist is medically necessary.
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 breast cancer examination. Findings: Two physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has dense breasts. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, the digital breast tomosynthesis 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 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. 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

Physician 1This patient is a 37-year-old woman who sustained a compression fracture at L-1 in December 2003 after being thrown from a horse. The patient reports problems with constant pain, although a back brace has provided some benefit. The patient has requested authorization for kyphoplasty. The Health Plan has denied the request indicating that the requested procedure is experimental in nature.The patient is a young woman without osteoporosis. This patient has not tried bracing and has only attempted medical management for a short time. The medical literature suggests that younger persons with compression fractures heal and do very well with bracing for three months. The literature does not support kyphoplasty over conservative management in the patients age group. As such, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2The patient is a 37-year-old woman who sustained a compression fracture at L1 two months ago. She has persistent pain. The patient has requested authorization for kyphoplasty. The Health Plan has denied her request indicating that kyphoplasty is considered experimental in nature.Kyphoplasty has been utilized increasingly over the years. The procedure is designed to alleviate pain and occasionally restore height to the vertebral body. This patient, with a L1 compression fracture and persistent pain, would be a candidate for kyphoplasty if she does not respond to medication, rest, and time. I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld at this time. However, if documentation is provided that the patient has failed continued attempts at conservative management, then the patients request for kyphoplasty should be reconsidered.  Physician 3The patient is a 37-year-old woman with a traumatic compression fracture. The patient is young and healthy with no signs of osteoporosis. She has requested authorization for kyphoplasty. The Health Plan has denied the patients request.No controlled perspective studies exist to document intermediate or long-term safety and efficacy of kyphoplasty in single or multiple compression fractures. There is no evidence that shows that kyphoplasty actually increases the height of the vertebrae or restores alignment. Additionally, the patient is a young, healthy woman without osteoporosis. Given these factors, kyphoplasty is not medically indicated for this patient and is not likely to result in greater benefit than conservative therapy.Based upon the information set forth above, I have determined that the requested procedure is 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.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested a 24-week course of Sovaldi 400mg (once a day) and ribavirin 600mg (twice per day) for medical treatment of her hepatitis C. Findings:  Two physician reviewers found that the American Association for the Study of Liver Diseases and Infectious Diseases Society of America note that the evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The requested 24-week course of Sovaldi 400mg (once a day) and ribavirin 600mg (twice per day) is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 37-year-old male enrollee has requested average volume assured pressure support (AVAPS) treatment and related accessories for treatment of his obstructive sleep apnea. Findings:  Two physician reviewers found that although the records provided for review support a diagnosis of OSA, there is insufficient documentation to confirm a diagnosis of obesity hypoventilation. As there are no carbon dioxide (CO2) levels available for review, it is difficult to ascertain whether use of the AVAPS resulted in improvement of the patients CO2 levels. Given that the provider recommended the treatment at issue, it may be that the patients CO2 levels have in fact improved with use of AVAPS, thus making its use more reasonable. If documentation was provided showing improved CO2 levels, it may be recommended based upon that data. At this time, the equipment at issue remains investigational or experimental in this clinical setting.