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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for Residential Treatment Center (RTC) services. The submitted documentation supports the medical necessity of both the services at issue and the requested services going forward. The American Psychiatric Association treatment guidelines for Substance Use Disorders recommends that residential treatment, or similar care higher than outpatient, is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use, and who lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. Such patients require safe and stable living environments in order to develop their recovery skills, thus qualifying for ASAM Level III treatment, which is at least residential treatment center services similar to what the patient received at the facility in this case. The evaluation of treatment documentation requires an understanding that patients conditions wax and wane. A relatively positive documentation by one patient on one day does not indicate a spontaneous cure or that the patient is in the clear, for it simply denotes progress and that treatment is working, which is an indication to continue not cease treatment. While the purpose of detoxification is to make a patient physically stable and safe, rehabilitation is the essential component that should follow detoxification, and the purpose of rehabilitation is to help the patient maintain sobriety and reduce risk of relapse. In this case, given the severity of the patients illness, Residential Treatment Center services were and are in accordance with generally accepted standards of medical practice and are clinically appropriate for the patient's illness. Accordingly, the Residential Treatment Center (RTC) services at issue, and the requested services, were and are medically necessary for treatment of the patients condition.Final Result: The reviewer determined that the services at issue and requested services were, and 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla for treatment of the enrollees plaque psoriasis. Findings:  The physician reviewer found that there is support in the medical literature for the requested medication in this clinical setting. In an undated letter, a provider reported that biologics have been avoided due to their immunosuppressive properties, side effects and previous treatment failures. This patient has tried and failed therapy with Humira and this patients treating provider does not recommend treatment with additional immunosuppressive agents.  Otezla is a U.S. Food and Drug Administration (FDA) approved oral agent for the treatment of psoriasis and psoriatic arthritis. Its safety profile does not require any routine blood monitoring for systemic side effects. The patient has tried and failed therapy with an injectable systemic biologic agent and has failed treatment with immunosuppressive therapies. Therefore, Otezla is medically necessary for the treatment of the patients medical condition. 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sacroiliac (SI) joint injections for treatment of her neck and SI pain. Findings:  Three physician reviewers found that the request for SI joint injections are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Researchers conducted a meta-analysis which demonstrated that [radiofrequency] RFA is an effective treatment for SI joint pain at 3 months and 6 months. This study is limited by the available literature and lack of randomized controlled trials. Further standardization of RFA lesion techniques needs to be established, coupled with prospective randomized controlled trials. Thus, this technique needs further investigation. In addition, clinical practice guidelines state that the evidence supporting radiofrequency lesioning is limited. Final Result: The 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: Reviewers 1, 2, and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine and is 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: Medical Necessity
Decision: Overturned

A 60-year-old male enrollee has requested for laparoscopic robotic-assisted radical prostatectomy for treatment of his prostate cancer. Findings:  The physician reviewer found that there are several areas in which the laparoscopic and open (standard) radical prostatectomy may be compared. As far as the risk of complications is concerned, there is now enough evidence accumulated over time from multiple sources to be able to conclude that the two types of surgical procedures have comparable complication rates. In addition, there is now adequate evidence to conclude that cure/survival rates of laparoscopic and open radical prostatectomy are comparable. With regard to the technical aspects of the two procedures, the laparoscopic approach is less traumatic to the patient than the open incision approach, often resulting in easier recovery. Given that the robotic-assisted laparoscopic radical prostatectomy is superior in ease of patient recovery following surgery, it has a distinct advantage over the standard surgical approach and as such, is clinically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old female enrollee has requested intravenous immunoglobulin (IVIG) with rituximab for treatment of her pemphigus vulgaris.  Findings:  Three physician reviewers found that rituximab has clearly been shown to be efficacious for the treatment of pemphigus vulgaris. IVIG has also been shown to be effective for this condition. There are some reports in the available peer reviewed literature of utilizing both therapies concurrently. However, based upon the documentation provided, it does not appear that this patient has undergone a trial of rituximab alone. Rituximab should be attempted as a stand-alone therapy prior to consideration of combining rituximab and IVIG. If a trial of rituximab as solo therapy is not efficacious in treating this patients condition, then combination therapy with rituximab and IVIG would be appropriate and should be pursued.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old female enrollee requested authorization and coverage of gastric bypass surgery for the treatment of morbid obesity.  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 overturned the health plans denial on the basis that the requested surgery is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old male enrollee has requested intensity modulated radiation therapy for treatment of his prostate cancer. Findings:  The physician reviewer found that intensity modulated radiation therapy is the optimal form of radiation when treating prostate cancer postoperatively. The Health Plan has cited a 75Gy minimum dose cutoff in the denial of coverage. The 75Gy minimum prescription dose cutoff for establishing the medical necessity of intensity modulated radiation therapy in the primary treatment of prostate cancer should not be applied to the postoperative setting. Specifically, margins are larger, and a cuff of the bladder is intentionally included within the target. Also, the target volume is significantly influenced by variable bladder and rectal filling and is biconcave in its superior portion, all favoring intensity modulated radiation therapy. In this patients case, intensity modulated radiation therapy is medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old male enrollee has requested for a Dual Energy X-ray Absorptiometry (DEXA) scan for evaluation of his osteopenia. Findings:  The physician reviewer found that the results of the patients first DEXA scan revealed a low T-score, but based on guidelines, the T-score is not to be used in men under the age of 50. If the Z-scores are used, as recommended by the NOF and the ICSC, none of them are under -2.0. Therefore, this patients bone density is within the expected range for his age. The patient was properly counseled to take Vitamin D supplementation. However, there is no indication in the medical records provided that the patient had any special need to necessitate a bone mass density test prior to age 50. There are also no medical records provided that show the patient had a fragility fracture or any other risk factor for osteoporosis or a progression to osteoporosis.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hydrocodone/APAP 10/325 mg, #60 per 30 days for treatment of the enrollees pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has migraine headaches and abdominal pain for which she has been taking hydrocodone/APAP.  This is not recommended therapy for migraine headaches and is of questionable value for nonspecific abdominal pain.  The patient noted she had back pain after an automobile accident, but there is no documentation of a physical examination confirming lumbar radiculopathy or back injury, nor is there imaging to confirm back pathology.  Clinical practice guidelines do not support prescribing opiates in this clinical setting.  All told, hydrocodone/APAP 10/325 mg, #60 per 30 days is not medically indicated 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 physician 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: Medical Necessity
Decision: Upheld

The patient is a 68-year-old man with a history of renal failure due to obstructive uropathy, which is likely due to a history of a long-standing enlarged prostate. He wishes to have a kidney transplant. The transplant team recommends he have urologic evaluation, and possible transurethral resection of the prostate (TURP) to decrease the risk of obstructive uropathy effect on the possible kidney transplant. The patient notes he has seen urologists in the past who have recommended he have a TURP procedure, but he has always refused. The patient believes his kidney failure is due to salt overload and he is attempting exercises to help his prostate. The patient does not wish to undergo a TURP procedure as recommended by his provider. He wishes to be listed for kidney transplant without urologic clearance. A note from Scripps hospital in December 2003 indicates that during the patients admission for kidney failure an ultrasound showed bilateral hydronephrosis. Furthermore, there is evidence the patient had a markedly distended bladder at the time of his presentation with kidney failure. Both of his kidneys and his bladder showed the effects of back pressure from bladder obstruction, which is commonly due to prostate problems in men. It is very likely that his kidney function failed due to obstruction of urine flow by his enlarged prostate. It is highly unlikely that the major cause of the patients kidney failure was from excess salt intake as the patient suggests.There is a high likelihood of early failure if a kidney was to be placed without fixing the patients obstruction. A transplant kidney is usually placed in the anterior pelvis, lower down than native kidneys and therefore, is at higher risk of reflux due to the surgical opening created in the bladder as well as less benefit from gravity. Urine usually has to flow uphill to produce back pressure on native kidneys; there is less of a gradient and therefore, easier reflux back into a transplant kidney if the bladder is obstructed. In addition, urinary tract infections are more likely when the bladder does not allow for emptying. The immunosuppression required for transplantation also increases risk of infection; adequate bladder emptying is required. The patient may have to wait several years for his transplant. Even if he has a TURP procedure now it is not clear that his bladder will function normally after a transplant. He may need to perform self-catheterization. Still, for the reasons stated above the patient does require a plan for adequate bladder drainage by a urologist before he receives a transplant. At the present time, a urologist might suggest other therapy than a TURP. In any event, it is essential this patient obtain clearance by a qualified urologist prior to his kidney transplantation. Therefore, I have determined that 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

A 31-year-old male enrollee requested authorization and coverage of an inferential stimulator for the treatment of fibromyalgia and chronic fatigue syndrome.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that an inferential stimulator  is not likely to be more beneficial for treatment of the enrollees fibromyalgia and chronic fatigue syndrome than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld

A forty-five year-old obese female is requesting authorization of requested gastric bypass surgery.  The patient has no documented life threatening comorbidities. Reviewers Findings:  The reviewing physician found that the patients current level of minimal obesity with minimal comorbidities, the requested surgery is not medically necessary.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lymphovenous bypass surgery (CPT 38999). The records provided for review document that this patient has a history of left lower extremity lymphedema secondary to prostate cancer. The patients provider has recommended treatment with lymphovenous bypass surgery. The consensus document from the International Society of Lymphology (ISL) states that lymphovenous anastomoses (LVA) have undergone confirmation of long-term patency and some demonstration of improved lymphatic transport. The ISL noted that, Multiple lymphaticovenous anastomoses in a single surgical site with both the superficial and deep lymphatics, allow the creation of a positive pressure gradient (lymphatic-venous) and evade the phenomenon of gravitational reflux without interrupting the distal peripheral superficial lymphatic pathways. Garza and Chang found that the benefits of the procedure include its effectiveness in treating early-stage lymphedema of either the upper or lower extremity and having low complication profile. Based on the current evidence-based literature, the requested lymphovenous bypass surgery (CPT 38999) is 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 lymphovenous bypass surgery (CPT 38999) is 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 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: Physician reviewer 1 is board certified in vascular surgery and is actively practicing. Physician reviewer 2 is board certified in vascular surgery and is actively practicing. Physician reviewer 3 is board certified in vascular surgery and is 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acupuncture services two times a week. Findings:  The physician reviewer found that Acupuncture is effective for the treatment of chronic musculoskeletal, and osteoarthritis pain. Per the authors, Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain. An initial trial of acupuncture, which may be indicated for chronic neck pain, generally consists of five to six appointments, with a re-evaluation after the trial is completed to assess the benefits obtained. In this case, the patient has received multiple sessions of acupuncture over several months, without documentation of significant, objective benefits. The documentation did not demonstrate significant symptom reduction, or improvement of activities of daily living functioning directly attributable to prior acupuncture. Given that measurable, progressive, significant, objective functional improvement has not been noted,  the requested services are  not medically indicated. Therefore, acupuncture services two times a week are not medically necessary for the treatment of 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 a licensed acupuncturist, board certified in oriental 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 gene testing. Findings:  The three physician reviewers found this patient was suspected to have Muir-Torre syndrome based on her skin biopsy and family history. Muir-Torre syndrome is a rare autosomal dominant condition characterized by the association of at least one sebaceous skin tumor and at least one visceral malignancy. Muir-Torre syndrome is caused by germline mutations in the DNA mismatch repair genes and is considered a phenotypic variant of hereditary nonpolyposis colorectal carcinoma syndrome. Internal malignancies most frequently associated with Muir-Torre syndrome include colorectal, endometrial, ovarian, and urothelial cancers. The patient meets criteria for testing. Therefore, gene testing was likely to have been superior over other methods of evaluating this patient. 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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.