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

A 71-year-old male enrollee requested authorization and coverage for proton beam therapy. The health plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees early-stage prostate cancer.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient reports a history of anxiety/tension and menstrual cramps. She indicates she has been experiencing anxiety since her last two miscarriages. The patient has a strong desire to become pregnant and to avoid a miscarriage. She is concerned about the risks associated with anti-anxiety medications. It appears the patient has benefited from an acupuncture treatment she previously received. A request has been made for authorization and coverage for acupuncture, which has been denied by the Health Plan. Anxiety/depression is a condition that is commonly treated with acupuncture. Additionally, acupuncture has been used with success in the treatment of gynecological disorders. The patient indicates she has achieved good results from an acupuncture treatment she received in the past. It is likely that additional acupuncture treatments will improve the patients anxiety and reduce her menstrual pain. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should receive eight acupuncture treatments followed by re-evaluation by her acupuncturist and primary care physician.
Appeal type: Medical Necessity
Decision: Overturned

This patient is an eight-year-old female with a history of global developmental delay with hypotonia, oral motor dyspraxia, and seizure disorder. The seizure disorder has been treated with Lamictal and she has had approximately 3-4 focal motor seizures since October 2004.  Each time the patient has jerking of the right hand and foot. The patients therapist has documented a regression in speech after each of the seizures and the neurologist and rehabilitation physician have documented weakness, right greater than left.At issue is whether continued speech therapy is medically necessary for treatment of the patients condition.Though no physician states that the patients speech deficits are directly related to the seizures, the proximity of the motor strip on the left to the speech pathways make it likely that her speech is being affected by the seizures, particularly since the therapist has documented decreased performance after the seizures. This, in conjunction with the patients significant poor oral and motor skills make it highly probable the patients condition is related to a disease state. Additionally, the patients therapist has documented steady gains with therapy from 2000-2005. Therefore, continuation of the current therapy is medically reasonable and appropriate. Based upon the information set forth above, I have determined that 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 54-year-old female has requested a bilateral bunionectomy for treatment of her foot pain.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested procedure.  In this patients case, surgical intervention is necessary for the treatment of the patients medical condition.  The medical records support the diagnosis of hallux limitus.  Her physical examination correlated with the x-ray findings.  The patient continues to have significant pain involving both feet.  The documentation noted daily use of ibuprofen.  The current medical evidence supports the requested procedure in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old male enrollee requested authorization and coverage of a pancreas transplant. The Health Plan denied the enrollee's request indicating that the requested treatment is not medically necessary for the treatment of the enrollees renal failure.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 for the treatment of the patient's medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the bilateral breast tomosynthesis performed.  Findings:  The physician reviewer found that the patient who is asymptomatic with respect to her breasts. On date of dispute, she underwent a routine screening mammogram consisting of a three-dimensional tomosynthesis study with synthetically reconstructed two-dimensional views. The current images were compared to prior mammograms  and no interval changes were noted. There were no masses, areas of suspicious calcifications, or areas of architectural distortion. Her breasts were described as average in density. The patient has requested reimbursement for the bilateral breast tomosynthesis performed on date of dispute. The Health Plan has denied this request as investigational. Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. However, in this case there were no problems to be resolved. The patient did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. In this case, a routine mammogram would have been sufficient. Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there has been no change when compared to prior mammograms. Therefore, the bilateral breast tomosynthesis performed on date of dispute was not 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 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: Physician reviewers  number 1,2 & 3 are board certified in diagnostic radiology and are  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 has requested a colonoscopy for evaluation of her abdominal pain. Findings:  The physician reviewer found that this patient has a long history of epigastric pain. This is associated with nausea and vomiting.  The patient has undergone ultrasound which was remarkable for fatty liver disease. Amylase and lipase were evaluated twice, during episodes of pain, and were normal.  EGD was done and revealed gastritis and hiatal hernia.  Approximately two years ago, colonoscopy was remarkable for diverticulosis and three polyps (one tubular adenoma and two hyperplastic).  As per the American College of Gastroenterology guidelines, a colonoscopy for surveillance is indicated every five years in this clinical scenario. All told, the requested colonoscopy is not medically indicated for this patient at this time.
Appeal type: Experimental/Investigational
Decision: Upheld

A 39-year-old male enrollee has requested transcranial magnetic stimulation for treatment of his major depressive disorder.  Findings:  Two physician reviewers found that according to peer-reviewed literature on the topic of antidepressant treatment, there are varying reports on the efficacy, especially long-term, and potential side effect profile and case selection for benefit of repetitive transcranial magnetic stimulation (rTMS).  Gross and colleagues provided an updated meta-analysis of studies related to this treatment modality.  The authors reported that although results are suggestive that rTMS has significant antidepressant effects, larger multicenter studies are necessary to confirm these trends.  Gershon and colleagues also reported positive responses of rTMS as an antidepressant treatment, but noted continued need for verification and standardization of best practices and type of patient that would benefit. According to their review, the absence of psychosis, younger age, and certain brain physiologic markers might predict treatment success. Technical parameters possibly affecting treatment success include intensity and duration of treatment, but their summary suggestion is for ongoing systematic testing.  Lam and colleagues concluded that for patients with treatment-resistant depression, rTMS appears to provide significant benefits in short-term treatment studies. However, the relatively low response and remission rates, the short durations of treatment, and the relative lack of systematic follow-up studies suggested that further studies of rTMS are needed.  All told, at this time, the superior efficacy of the requested transcranial magnetic stimulation has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old male enrollee requested authorization and coverage of gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested procedure is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer 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 two of the three  physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for pimecrolimus 1% cream (Elidel). Researchers describe Hailey-Hailey disease as an inherited disease that presents with lesions typically distributed symmetrically within intertriginous regions such as the retroauricular folds, lateral aspects of the neck, axillae, umbilicus, inguinal, and perianal regions. The authors report that treatments include topical and systemic agents. Medical literature note that topical immunomodulators, such as pimecrolimus, may lead to an improvement of the clinical picture of patients with Hailey-Hailey disease. In this case, the patients disease involves areas in the armpit and breasts. She has responded well to triamcinolone and Elidel for maintenance therapy. As such, in this clinical setting, the requested medication is medically indicated. Therefore, pimecrolimus 1% cream (Elidel) is medically necessary for the treatment of this patient.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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested magnetic resonance imaging (MRI) of the right foot for evaluation of his suspected osteomyelitis. Three physician reviewers found that in the medical literature, Pineda and colleagues noted that MRI allows early detection of osteomyelitis and assessment of the extent of involvement and the activity of the disease in cases of chronic bone infection. The authors further state that MRI is considered the most useful imaging technique to evaluate suspected osteomyelitis because of its ability to demonstrate changes in the water content of bone marrow with an excellent structural definition and spatial resolution. MRI is highly sensitive for detecting osteomyelitis as early as 3 to 5 days after the onset of infection. Kothari and colleagues reported that nuclear medicine and MRI are the most sensitive and most specific imaging modalities for the detection of osteomyelitis. All told, the peer-reviewed medical literature supports the MRI of the right foot as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts 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 59-year-old female enrollee requested authorization and coverage of a muscle biopsy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for evaluation of the enrollee for possible malignant hyperthermia.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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested BRCA gene testing for evaluation of her medical condition.  Three physician reviewers found that screening for BRCA mutations is indicated in individuals whose personal or family history predicts a high likelihood of finding one of these mutations.  Identifying individuals who carry these mutations has clinical importance in that it mandates the adoption of special measures aimed at risk reduction.  Well-established guidelines identify those individuals in whom genetic screening is warranted.  Per National Comprehensive Cancer Network guidelines, an individual with a first-degree relative with breast cancer diagnosed younger than age 50 is eligible for BRCA testing.  This patients relative was diagnosed with breast cancer at age 38.  All told, BRCA gene testing was likely to be of greater benefit than other modalities for evaluating this patient.  Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in 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: Upheld

The parent of a 14-year-old male enrollee has requested Increlex therapy for treatment of his short stature due to Cystic Fibrosis.   Findings:  The physician reviewer found that Cystic fibrosis is usually associated with short stature due to chronic lung infections, pancreatic steatorrhea and anoxia as complicated by diabetes. IGF-1 levels tend to be low because of poor nutritional status. Vigorous management of these factors is associated with better growth outcomes. At this time, there are insufficient studies documenting that IGF-1 therapy results in a worthwhile anabolic effect and growth response in cystic fibrosis patients. The benefit of Increlex remains unproven in this setting and the therapy could worsen the diabetic state.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. The patient was at risk of subacute withdrawal given his premorbid level functioning. The patients risk of subacute withdrawal symptoms was elevated due to comorbid obsessive-compulsive disorder (OCD) and attention-deficit/hyperactivity disorder (ADHD). 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 psychiatry with expertise in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Xifaxan  for treatment of her irritable bowel syndrome with diarrhea. The physician reviewer found that the current medical supports the requested medication for the treatment of this patient.  Xifaxan has been demonstrated to be effective for treatment of symptoms in irritable bowel syndrome with diarrhea in multiple randomized controlled trials.  Further, cyclic therapy has proven to be effective, and intermittent treatment can result in prolonged relief of symptoms.  In this patients case, prior treatment with Xifaxan resulted in symptom improvement.  Based upon the medical literature, the requested Xifaxan  is medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 61-year-old female that indicates that she has been sewing for 46 years, but her excess arm skin is impeding her ability to work.  The patient has undergone gastric bypass surgery.  Prior to her bypass, she had excess arm skin and arm lipodystrophy.  The gastric bypass did not create extra skin but probably has resulted in a decrease in arm fat, which makes the arm skin looser. The weight loss should have improved the patients ability to perform her job properly and therefore her complaints of functional impairment are not substantiated by the record. At issue is whether a bilateral brachioplasty is medically necessary for treatment of the patients condition.The submitted medical records and photographs of the patient demonstrate hanging skin and subcutaneous fat but no indication of medical necessity for the proposed brachioplasty. There is no evidence of any skin rash or infection on the patients arms. In addition, as noted above, her claim that she cannot perform her job is not substantiated by the submitted clinical information. Moreover, there is no evidence in the peer-reviewed medical literature showing that excess arm skin causes arm fatigue or that brachioplasty improves arm function. In summary, the records do not convincingly document that this patient has a functional problem related to her arm skin. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Qvar Aer w/adaptor.Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has had asthma for a long period of time. The documentation provided does not include a report of symptoms associated with her asthma. The medication list indicates she is prescribed albuterol three times daily. However, the records do not include a review of symptoms that would reflect the need for rescue inhaler this frequently, nocturnal awakenings due to symptoms, limitation in normal activity or pulmonary function studies. Based on the clinical notes provided, the category of asthma severity is unclear. When treating a patient with asthma, the recommendations are for a stepwise approach to therapy. A low dose inhaled steroid is recommended when the patient has mild persistent asthma. For moderate persistent asthma, the preferred therapies are either low doses of an inhaled glucocorticoid plus a long-acting inhaled beta agonist, or medium doses of an inhaled glucocorticoid. In this case, it is unclear how severe the patients symptoms and disease are. Thus, the medical necessity for an inhaled glucocorticoid is not established. Therefore, Qvar Aer w/adaptor 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 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.