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

The patient has requested reimbursement for (1) bilateral breast implant removal surgery and (2) breast surgery (bilateral breast mastopexy). Tervaert and colleagues state, Autoimmune/inflammatory syndrome by adjuvants (ASIA), allergies, autoimmune diseases, immune deficiencies and lymphomas occur in patients with silicone breast implants. There is a need for adequately adjusted epidemiological studies to ascertain the frequency of these diseases. However, Balk and colleagues state, The evidence remains inconclusive about any association between silicone gel implants and long-term health outcomes. Chao and colleagues report, Breast implant surgery is one of the most commonly performed procedures in the field of plastic surgery. While silicone implants are now routinely used in breast surgery, they have previously been the subject of controversy. This was particularly true in the U.S., where there was a moratorium on their use from 1992 to 2006. Following subsequent scientific validation of their safety, silicone implants have regained widespread acceptance for clinical use. Overall, silicone breast implants are associated with a high degree of patient satisfaction and low rates of complications. Further independent research is necessary to better establish long-term outcomes. In this case, the patient reported generalized complaints associated with silicone breast implants. The documentation also noted that the implants that were removed were saline filled implants, not silicone gel implants. Given that current medical literature does not support the association of the patients symptomatology with her breast implants, the bilateral breast implant removal surgery was not medically indicated. While the provider noted that patient may not like the aesthetic of her breasts post removal and may request a mastopexy, breast surgery (bilateral breast mastopexy) was not medically indicated. Therefore, (1) bilateral breast implant removal surgery and (2) breast surgery (bilateral breast mastopexy) was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Otrexup for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Treatment with the prefilled form of injectable methotrexate is not medically necessary in this patient. There is no documentation to support why the regular form of injectable methotrexate is not acceptable, not efficacious or intolerable. On the basis of the available medical records, Otrexup 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 reviewer is board certified in internal medicine with sub-specialty certification in rheumatology 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 26-year-old female enrollee has requested transcutaneous electrical nerve stimulation (TENS) unit for treatment of her low back pain. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested device. TENS is not recommended as a first-line treatment modality for chornic back pain (Khadilkar et al). Moreover, there is a lack of medical literature that supports the effectiveness of TENS in chronic pain. Carroll and colleagues evaluated the effectiveness of TENS in chronic pain and concluded that The results of this review are inconclusive; the published trials do not provide information on the stimulation parameters which are most likely to provide optimum pain relief, nor do they answer questions about long-term effectiveness. Large multi-centre randomised controlled trials of TENS in chronic pain are urgently needed. In addition, there is no evidence provided that shows that appropriate pain modalities have been tried and failed. There is also no documentation of a short and long term treatment plan. Based upon the documentation submitted for review and the peer-reviewed literature cited above, the medical necessity of the requested device has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the residential treatment services provided Findings:  The physician reviewer found that the records provided for review indicate that this patients post-acute withdrawal symptoms were mild to moderate and could have been managed symptomatically as an outpatient. He was not a danger to himself, and he was not aggressive or self-injurious. There were no emotional, behavioral, or cognitive issues that would have required residential services. He was not manic, psychotic, or agitated. He was medically and psychiatrically stable. He did not show signs or symptoms of bipolar disorder. He attended and participated in all forms of treatments provided. He has a past history of multiple substance abuse treatments at different levels of care, therefore the process and AA program are familiar to him. He was aware of the consequences that his substance use had on his relationships, employment, and education. He recognized his triggers and demonstrated that he was capable of sustaining a prolonged period of sobriety. He had not undergone a lower level of care within the prior year. Although relapse risk was present, this patient could have been treated outside of the restrictive 24-hour residential environment, and entered treatment in an ambulatory setting such as an intensive outpatient program (IOP). In conjunction with this, he could have concurrently attended AA, worked with a sponsor, and found other community support groups. All told, the residential treatment services were not medically necessary for treatment of the patients medical condition.Final Result: The reviewer 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 reviewer is board certified in psychiatry with sub-specialty certification 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the ice machine combined cooling/heating device. Review of current medical literature does not indicate that the ice machine combined cooling/heating device provided was likely to be more beneficial for the treatment of the patients condition than any standard available therapy. While researchers reported that continuous flow cold is superior to crushed ice for outpatient ACL [anterior cruciate ligament] reconstruction pain and should not be considered an equivalent modality, there is a paucity of data demonstrating that the device results in superior health outcomes in bunion surgery. Thus, the ice machine combined cooling/heating device was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the ice machine combined cooling/heating device was 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 ice machine combined cooling/heating device was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Medical professional reviewers 1, 2 and 3 are board certified in podiatry 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for emergency medical services. Findings:  The physician reviewer found that The services at issue were necessary for treatment of an emergency medical condition. In this case, the patient presented to the emergency department with a dog bite the day prior. The dog had not been vaccinated for rabies. The patient had pain and puncture wounds to the calf. Dog bites must be emergently evaluated to assess for rabies exposure. Rabies can be prevented with injection of rabies immune globulin. The more timely the administration, the lower the risk of developing rabies. Even though this patient presented the day following the dog bite, rabies immune globulin should not be delayed if rabies exposure is suspected. In addition, dog bite wounds to the extremities should receive antibiotic prophylaxis to prevent infection. The sooner those antibiotics are initiated, the lower the risk of infection. The care provided to this patient in the emergency department meet the criteria for emergency services as defined above. Thus, the services provided were for emergency services.  Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in emergency 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 has requested authorization and coverage for a lift recliner chair, or in the alternative, a semi-electric adjustable hospital bed with remote. Based on the available documentation, the requested lift recliner chair, or in the alternative, a semi-electric adjustable hospital bed with remote is not medically necessary for this patient. The records do not demonstrate that the patient is unable to elevate his legs in a standard recliner or that he has upper or lower extremity weakness with limited ability to go from a seated to a standing position. There is a lack of evidence in current medical literature that there is a relationship between sleep posture and spinal symptoms (Cary, et al.). In addition, a semi-electric adjustable hospital bed with remote is not medically necessary for this patient. This patient has a normal gait, normal upper and lower body strength without evidence of a frequent need to change positions. The physician reviewer found that  there is no evidence that the patient is unable to position his body in ways not feasible with an ordinary bed or that he requires traction equipment. The provider noted that the patient is currently independent with bed mobility. The physical therapy DME evaluation indicated that a semi-electric adjustable hospital bed is not appropriate for this patients condition. All told, the requested lift recliner chair, or in the alternative, a semi-electric adjustable hospital bed with remote, is not medically necessary for this patient.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.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old female enrollee has requested for uro-gynecology services and uro-physical therapy services for treatment of her pelvic floor tension myalgia.   Findings:  The physician reviewer found that Rosenbaum and Owens concluded that physical therapy treatment of pelvic pain is an integral component of the multidisciplinary approach to chronic pelvic pain and associated sexual dysfunction. Criscuolo also concludes that interventional therapies are a valuable addition to treatment of myofascial pain syndromes.Furthermore, with regard to the uro-gynecology services at issue, Montenegro concluded that trigger point injections can be effective in the management of chronic pelvic pain.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) rehabilitation services including physical therapy. Based on the documentation provided for review and medical literature, this patient does not require SNF services with the specialized skill, knowledge and judgment of a skilled nurse to administer medical treatment. The records do not indicate that the patient has a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. The patients current functional level does not require ongoing SNF level skilled therapy services. Although the patient is likely to benefit from physical therapy services, the patient does not require these services on a daily basis. All told, the SNF rehabilitation services including physical therapy were not and are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with subspecialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for bilateral breast tomosynthesis performed. Findings:  The physician reviewer found that the patient reported a family history of breast cancer. The patient underwent a routine screening mammogram consisting of a synthetically reconstructed two dimensional views with three dimensional tomosynthesis study. 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 being dense. Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts.  In this particular patient, the patients breast tissue was described as being dense. While her mammogram has not changed since the last study, it is specifically those patients who have dense tissue that can benefit most from digital breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. board certified in diagnostic radiology and is actively practicing. Credentials/Qualifications: the physician 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: Urgent Care
Decision: Upheld

A male enrollee requested air ambulance transport services on an emergent basis.   Findings:  The physician reviewer found that air ambulance is indicated under certain circumstances. However, in such circumstances, the transport is covered to the closest facility capable of providing adequate care. This patient was not transferred to the closest facility capable of providing care. Although the patient required continued care in a rehabilitation facility, his transfer there was not emergent or urgent, and was scheduled in advance.  Further, there is a lack of evidence in the literature that any one particular institution is required for the treatment of a particular patient. Thus, a prudent layperson would not have reasonably expected the absence of the air ambulance transport services to have resulted in serious bodily impairment and were not provided on an emergent basis.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of the enrollees hepatitis C virus. Findings: The physician reviewer found that the medical necessity of HCV eradication as per American Association for the Study of Liver Diseases/Infectious Diseases Society of America (AASLD/IDSA) recommendations exists irrespective of fibrosis score. AASLD/IDSA guidelines underscore this position with the following statement: Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months). The records provided demonstrate that this patients life expectancy exceeds this limit. However, in this case, the provider requested a 12-week course of Harvoni.  In patients with viral loads less than 6 million IU/mL, an 8-week course of Harvoni is considered medically appropriate. Kowdley and colleagues state, `Ledipasvir-sofosbuvir for 8 weeks was associated with a high rate of sustained virologic response among previously untreated patients with HCV genotype 1 infection without cirrhosis. No additional benefit was associated with the inclusion of ribavirin in the regimen or with extension of the duration of treatment to 12 weeks.` This patient is treatment-naive without cirrhosis and according to the study performed by Kowdley and colleagues there is no additional benefit to an extended 12-week course of Harvoni in this clinical setting. Therefore, Harvoni for 12 weeks is not medically necessary for treatment of this patients HCV.  Final Result: The reviewer determined that the requested medication regimen 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 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

A 50-year-old female enrollee requested Sovaldi and Olysio for treatment of her hepatitis C genotype 1.   Findings:  Two physician reviewers found that preliminary evidence from this patients case indicates that she has normal liver function testing, a low viral load, and normal platelet count. She may have minimal liver fibrosis although the ultrasound result suggests more significant fibrosis. However, the patient must demonstrate some objective evidence of advanced fibrosis, such as grade 3 or greater, to support an indication for the requested combination therapy. All told, the requested Sovaldi and Olysio are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The spouse of a 60-year-old male enrollee has requested acute rehabilitation program to include physical, speech and occupational therapy for treatment of the enrollees traumatic brain injury.  Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. The patient sustained a severe brain injury over a year ago, and the benefit of acute rehabilitation accrues in the early stages of acute brain injury (Turner-Stokes et al). Moreover, the benefit of continued therapy after completion of the acute phase has not been established when the injury is severe (Turner-Stokes et al). A well-established concept in neurological rehabilitation is that continued therapy does not improve outcome when there is no neurological recovery. This patient has a severe injury and remains quadriplegic. Although regular exercise may help maintain his current functional status, acute rehabilitation is not likely to improve or change his neurological status. The maintenance of the patients neurological status does not require daily skilled therapy. Based upon the documentation provided, the medical necessity of the requested services has not been established.
Appeal type: Medical Necessity
Decision: Upheld

The parents of an 11-year-old male enrollee have requested authorization and coverage for the medication Concerta. The health plan has denied this request indicating that Concerta is not medically necessary for treatment of the enrollees ADHD.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting reimbursement for monitored anesthesia care. The enrollee underwent a screening colonoscopy. She has had prior surgeries and has not experienced issues with anesthesia. She is an American Society of Anesthesiologists class II risk and Mallampati class II. She was given intravenous propofol for monitored anesthesia care. A professional societys clinical practice guidelines indicate anesthesia provideradministered sedation comprises a sizeable proportion of procedural sedation for outpatient endoscopic procedures in the United States. Estimates are that over half of the colonoscopies are currently performed with monitored anesthesia care. The potential advantages to anesthesia provideradministered sedation for routine colonoscopy and upper endoscopy may include improved individual satisfaction, decreased distractions for the endoscopist, and shorter sedation and recovery times.Final Result: The reviewer determined that the requested service was medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 26-year-old male enrollee has requested for his inpatient stay for treatment of his acute substance abuse. Findings:  The physician reviewer found that there is no evidence that the patient had prior treatment for substance abuse and he was without any suicidal or dangerous ideation on admission. There was no indication of his inability to care for himself and he had no evidence of failed outpatient services.