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

A 27-year-old male enrollee requested inpatient psychiatric treatment for medical treatment of his behavioral health condition. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services.  This patient initially evidenced dramatic symptomatologies of psychotic illness.  Discharge would have been premature and likely would have resulted in undue morbidity.  The psychiatrist was titrating ziprasidone, a second generation antipsychotic.  Thus, inpatient psychiatric treatment was initially indicated.  However, the records do not support the medical necessity of subsequent inpatient psychiatric treatment.  Although the patient was still delusional at times, he had improved.  He was sleeping well and was not suicidal.  The patient was taking his psychotropic medication, and he responded well to nursing support and redirection.  The records indicate the acute syndrome had resolved and the acute level of care was no longer medically necessary.  Considering the peer-reviewed literature and community treatment standards, inpatient psychiatric treatment was initially medically indicated.  However, based on the documentation provided, subsequent inpatient psychiatric treatment was not and is not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Emgality syringe injections 120 mg/mL. Findings:  Two of the three physician reviewers found that Emgality has been U.S. Food and Drug Administration (FDA) approved for the treatment of migraine headaches. In addition, there is medical evidence that Emgality has a beneficial effect for patients with cluster headache as well. In this case, the patient experienced intractable cluster headaches that were resistant to several different drug classes. Furthermore, the patient had a documented successful trial of Emgality, which reduced the headache frequency by half. Given these findings, the continued use of Emgality syringe injections 120 mg/mL is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the requested medication is 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:  One reviewer is board certified in neurology with subspecialty certification in sleep medicine and is actively practicing. One Reviewer is board certified in neurology with subspecialty certification in neuromuscular medicine and is actively practicing. One Reviewer is board certified in neurology and is 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 42-year-old male enrollee has requested community based adult services (CBAS) for treatment of his medical conditions. Findings:  The physician reviewer found that the requested community based adult services (CBAS) are not medically necessary for treatment of the patients medical condition. Community based adult services are programs which provide skilled medical services for patients. The documentation submitted for review indicates that the medical necessity for the requested services has not been established. While the patient has a history of hyperlipidemia, insomnia, anxiety, poor eyesight, and loss of hearing, the patient is able to self administer medications and is independent in all activities of daily living, and exhibits no indication upon assessment of a mental health disorder. Based on the documentation submitted for review, the requested services were not medically necessary for treatment of the patients medical condition.
Appeal type: Urgent Care
Decision: Overturned

A 56-year-old male enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that due to his severe pain and feeling that he might faint, it is reasonable that the patient sought care at a closer emergency facility instead of attempting to drive a further distance.  The patient had no choice but to seek emergency care in order to achieve resolution of his severe pain.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old male enrollee has requested for referral and treatment by a neurologist who specializes in treating patients with multiple sclerosis (MS) for evaluation and  treatment of his MS.    Findings:  The physician reviewer found that patients with MS should be under the care of a neurologist, preferably one who is familiar with the disease and comfortable with caring for MS patients.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee requested weekly outpatient eye movement desensitization and reprocessing (EMDR) therapy for medical treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that EMDR is a well-accepted treatment for post-traumatic stress disorder.  In this patients case, the records provided do not substantiate a clinical diagnosis of post-traumatic stress disorder.  A comprehensive treatment plan was not submitted for review.  Additionally, items such as developmental history, past symptom manifestation, current symptoms and subsequent functional impairment, prior treatments, and previous barriers to recovery were not presented.  Finally, progress notes were not submitted for review.  Thus, elements commonly seen in mental health documentation, such as patient goals, chief complaint, mental status examination, sequential objective rating scales, physical examination, assessment, and interpretative summary or plan, were not provided.  In sum, based upon the documentation provided, the medical necessity of weekly EMDR therapy has not been established.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 17-year-old male with bronchial asthma. He received Xolair injection therapy between October 2004 and June 2005.  His provider indicates that while receiving Xolair, the patient was stable and did not require acute office visits or hospitalizations, and was able to return to school.  Prior to the institution of Xolair therapy, he had high absenteeism due to his symptoms.The Health Plan denied continued coverage for Xolair in June 2005. The patient experienced acute exacerbations of asthma in September 2005.  Off Xolair therapy he again required systemic steroids, as well as Advair, Singulair and Zyrtec. In October 2005, the patients provider indicated the patient had not been able to advance to optimal maintenance level on his allergy shots without Xolair, and that prior to Xolair therapy a DEXA scan showed the presence of osteoporosis. Based on the fact that the patients asthma worsened off Xolair therapy, the patients provider has requested that the therapy be reinstated.At issue is whether Xolair is medically necessary for treatment of the patients medical condition.Upon review of the submitted clinical evidence, the patient qualifies for treatment with Xolair in all categories, and is unable to use high dose inhaled corticosteroids and oral steroids due to a diagnosis of osteoporosis. Clinical criteria for Xolair therapy includes:  age greater than 12 years; allergic asthma; and asthma that has not responded to standard medication such as Advair, Singulair, and albuterol. The submitted records document that the patient continues to suffer from allergic asthma when limited to standard medication and is unable to achieve an optimum dose of allergy immunotherapy. Xolair anti-IgE therapy has been shown to be effective in advancing immunotherapy to effective doses.The physician letters, clinical notes, and letter from the patients parent clearly indicate that the patient responded to Xolair therapy and had a documented deterioration of asthma during a trial without Xolair therapy. Thus, continued Xolair therapy is medically necessary given the patients diagnosis and concurrent medical complications.Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old male has requested coverage for an MRI with contrast for evaluation of his extreme head pain.  Findings:  The physician reviewer found that the patient had a headache that was new in onset, and was severe enough to send him to the ER, take strong medications, and see a neurologist. The patient underwent a non-contrast CT scan, while in the ER, to rule out bleeding, a subarachnoid hemorrhage (SAH) or an acute finding. A full workup of the cause of the patients headache was not completed in the ER. The patients neurologist performed a complete history and physical.  Although no neurologic deficits have been identified, it is reasonable in this case to order a more definitive exam, to exclude a structural cause for the patients headache.  An MRI with contrast is superior to a non-contrast CT scan for this purpose, as clearly the headaches are new, and of different character than the patient has previously experienced.  For new onset headache, MRI with contrast would be superior to a non-contrast CT scan. All told, the requested diagnostic imaging is medically necessary for evaluation of the patients medical condition, given that his headaches are of a new characteristic and severity.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Dexilant 60 mg twice daily. The Health Plan has denied this request indicating that the requested medication dosage is not medically necessary for treatment of the enrollees gastroesophageal reflux disease (GERD).Findings:  The physician reviewer found that based on current medical literature, Dexilant 60 mg twice daily is not supported as medically necessary. A comparison of multiple proton pump inhibitors (PPIs), including omeprazole, lansoprazole, and pantoprazole, has found no difference in control and healing of GERD. Dexilant, unlike all other proton pump inhibitors, is released in an extended fashion. This delivery system results in an extended plasma concentration and a higher mean 24 hour intragastric pH than other proton pump inhibitors and once daily dosing is recommended. Additionally, the use of Dexilant at the requested dose of 60 mg twice daily has not been approved by the U.S. Food and Drug Administration and the prescribing information for Dexilant states that use of Dexilant 60 mg twice daily is associated with severe adverse effects including hypertension (Dexilant package insert).  For these reasons, authorization and coverage for Dexilant 60 mg twice daily is not supported as medically necessary for the treatment of the patients GERD. Final Result: The reviewer determined that requested medication dosage 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 anesthesiology 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 an office consultation with a dermatologist. Studies found that topical calcineurin inhibitors (TCIs), including tacrolimus and pimecrolimus, both as a monotherapy and in combination with phototherapy, should be encouraged in patients with vitiligo. However, reporters noted that because of its mechanism of action, a potential risk of adverse reaction in long-term use of topical tacrolimus included trichomegaly. This patient has vitiligo and has been using tacrolimus for approximately one year. Given the possible side effects of the currently prescribed medication, a consultation with a dermatologist is medically indicated. It is medically appropriate for this patient to receive an evaluation of her condition and confirmation that she is on the proper treatment for her condition. Therefore, an office consultation with a dermatologist is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old male enrollee requested authorization and coverage of a power-operated vehicle (POV) to assist with mobility.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested equipment 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 Supartz injection series in the right knee. Findings: Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has tried and failed other conservative treatments, including arthroscopic surgery, physical therapy, NSAIDs, and corticosteroid injections, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Supartz injection series in the right knee is medically necessary for the 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 board certified in orthopedic 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for low dosage Ketamine infusion for three to five days for treatment of the enrollees complex regional pain syndrome (CRPS). Findings:  The physician reviewer found that Connolly and colleagues performed a systematic review to examine and synthesize the available literature concerning the treatment of CRPS with Ketamine. The authors concluded that There is no high quality evidence available evaluating the efficacy of ketamine for CRPS and all manuscripts examined in this review were of moderate to low quality. Therefore, we conclude there is currently only weak evidence supporting the efficacy of Ketamine for CRPS, yet there is clearly a rationale for definitive study. In this case, the patient has undergone multiple outpatient infusions with subanesthestic doses of Ketamine and has had no lasting analgesic benefit. The request for three to five days ketamine infusion is not standard of care for CRPS as there is no evidence that such treatment provides long-lasting, durable pain relief. As such, the request for low dosage Ketamine infusion for three to five days is not likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy.  Final Result: All three reviewers determined that the requested service 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. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a breast pump for treatment of the enrollees lactation. Findings:  The physician reviewer found that based on current guidelines, a hospital grade electric pump is not medically necessary for most patients. While this infant was hospitalized for one night on day four of life, this was actually before the patient rented the hospital grade breast pump. The American College of Obstetricians and Gynecologists (ACOG) states that maintaining milk supply depends largely on frequency of milk removal through breastfeeding and through expressing milk (breast pumping or manual expression) when the woman and her infant are separated. However, there is no data to support the need for a specific type of breast pump. Similarly, the U.S. Breastfeeding Committee states that an electric pump is needed to maintain lactation when the mother is separated on a regular basis, or for a prolonged period of time, from her infant, as with returning to work. Similarly, a hospital-grade or rental-grade pump is needed to support initiation of lactation for mothers and infants who are separated due to illness, or who are unable to feed directly from the breast. In this patients case, neither of these circumstances existed during the pump rental period. Thus, the breast pump at issue was not medically necessary for treatment of this patients medical condition. 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 obstetrics and gynecology with sub-specialty certification in maternal and fetal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 26-year-old female enrollee requested authorization and coverage of an MRI of the lumbar spine. The Health Plan denied the request indicating that the requested MRI is not medically necessary for evaluation of the enrollees back and right leg pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested MRI is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a deceased enrollee has requested reimbursement for the Foundation One Heme Testing for evaluation of the enrollees malignant rhaboid tumor of the liver. Findings:  The 3 physician reviewers found that Hepatoblastomas arise from primitive cells that can differentiate into a variety of histologies which as a result can give rise to complex tumors. They typically present as well circumscribed lesions that can be as large as 20 cm. They are very rare and prognosis is usually poor. SMARCB1 gene germline mutations cause a rhabdoid tumor predisposition syndrome (RTPS). Individuals with this condition have an increased risk of developing aggressive cancerous growths, in particular rhabdoid tumors. An additional mutation that deletes the normal copy of the gene is needed for tumors to develop. Somatic mutations in both copies of the SMARCB1 gene result in absence of the SMARCB1 protein and result in noninherited (sporadic) rhabdoid tumors in children. Due to the rarity of this tumor there are a lack of established guidelines for treatment in this clinical setting. In this case, somatic tumor testing was performed. The presence or absence of a germline and somatic or bi-allelic somatic would be consistent with RTLS. This is significant in characterizing the syndrome and determining if other family members should be tested for the germline mutation. For the reasons provided, the Foundation One Heme Testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the testing 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 reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number two is board certified in pediatrics with sub-specialty certification in pediatric oncology and 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.Physician reviewer number three is board certified in pediatrics and clinical genetics 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.