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

The patient is a 61-year-old male with asthma and chronic obstructive pulmonary disease (COPD). According to progress notes dated between June 2004 and July 2004, his physician prescribed Alupent via nebulizer and Advair. Progress notes described rhonchi on lung exam. The patient was started on Xopenex. The submitted progress notes indicate that the patient continued to smoke cigarettes. The patient has requested authorization and coverage for Xopenex. The Health Plan has denied this request on the basis that Xopenex is not medically necessary for treatment of the patients medical condition.According to literature from the manufacturer of Xopenex, the indication for the drug is for use in bronchospasm. Xopenex has a higher affinity for human beta-adrenergic receptors than racemic albuterol. Since it is more specific, less cardiovascular side effects are noted such as tachycardia and arrhythmia. According to the submitted study by Lovtall, et al., racemic albuterol is comparable in efficacy to Xopenex. The standard of care is to use albuterol as meter-dose inhaler or nebulized treatments prior to using Xopenex. As such, use of Xopenex is not medically warranted at this time. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for immune globulin. The provider reports that this patient has a history of recurrent pneumonia in the context of poor response to pneumococcal vaccination. The patient has responded well to treatment with immunoglobulin replacement therapy . After stopping this therapy, he received Pneumovax, and had post vaccination antibody titers, which does not meet the accepted criteria of at least 70% titers. Therefore, the requested immune globulin is medically necessary for 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 subspecialty certification in allergy and immunology 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 39-year-old female enrollee has requested a lap band procedure for the treatment of her medical condition. Findings:  The physician reviewer found that there is concern regarding postoperative compliance at this time.  The patient gained weight while in a bariatric surgery program.  She appears unwilling to complete the surgical preparatory process.  Her written communications reflect significant anxiety and unrealistic expectations regarding the procedure.  The notes document non-compliance with surgical directions. If the patient remains compliant with the bariatric surgery program for one year and quits smoking, then coverage for the surgery should be reconsidered.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee has requested authorization for chemical dependency residential treatment services for treatment of his chemical dependency.  Findings:  The physician reviewer found that according to ASAM Adult Patient Placement Criteria, the patient does not meet criteria for RTC admission. The submitted clinical information demonstrates that upon admission to both facilities the patient was at no risk of withdrawal, there were no concomitant biomedical conditions and/or complications, and there were no emotional/behavioral/cognitive conditions requiring a 24-hour structured setting. Furthermore, the records provided show the patients readiness to change is high, he is able to control his use of alcohol, is not in danger of relapse without 24-hour monitoring and his recovery environment is not high risk.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the SmartPill Wireless Capsule Motility procedure for evaluation of her medical condition.  Findings:  Two physician reviewers found that there is a lack of support for the requested services in this clinical setting.  The SmartPill provides temperature data throughout the gastrointestinal tract.  Additionally, it provides pH data, but this is only used to estimate gastric emptying time and identify arrival in the cecum.  This patient already has a diagnosis of gastroparesis.  The information the SmartPill will provide is of limited value in this patients case, and the results are unlikely to influence management.  All told, the requested SmartPill Wireless Capsule Motility procedure is not likely to be superior over other methods of evaluating this patient.   Final Result: Two reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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

A 47-year-old male enrollee has requested for Vanos (0.1%) topical cream for treatment of his stasis dermatitis.    Findings:  The physician reviewer found that it is reasonable to require the use of at least two alternative class-I steroid creams because this patient has not had trials of at least two Health Plan formulary topical steroids in the very high potency group, Vanos (0.1%) is not medically necessary for this patient at this time.
Appeal type: Medical Necessity
Decision: Overturned

A 29-year-old female has requested a bariatric surgery consultation for evaluation of morbid obesity.  Findings:  The physician reviewer found that according to the American Society for Bariatric Surgery consensus statement, candidates for bariatric surgery should not be required to complete formal non-operative obesity treatment as a pre-condition for having bariatric surgery if they can document credible weight reduction attempts. Furthermore, the criteria for eligibility for bariatric surgery from the National Institutes of Health and the Society of American Gastrointestinal and Endoscopic Surgeons do not require physician-supervised obesity treatment prior to weight loss surgery.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patient has requested authorization and coverage for sildenafil 25 mg tablets. The records provided for review indicate that this patient is status post radical prostatectomy for treatment of prostate cancer. The patient has been treated with sildenafil, which the provider states has been beneficial for the patients neuropathic issues including urinary and bowel changes. The provider has recommended continued treatment with sildenafil. However, the available clinical documentation does not adequately define the patients symptomatology or identify specific improvements as a result of this medication. Furthermore, although medications such as solifenacin have been shown to improve overactive bladder, there is markedly less literature demonstrating any benefit in neurogenic bowel and bladder complaints with the use of sildenafil. Overall, there is a lack of documentation of specific symptoms being treated, improvement in those symptoms as a result of sildenafil, and medical literature support for continued treatment with sildenafil for these conditions. Given these findings, the requested sildenafil 25 mg tablets are not medically necessary for 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.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old male enrollee has requested hearing aids, Siemens Pure 701 Micon hearing aid with E charger and Mimi Tek remote for treatment of his hearing loss.  Findings:  The physician reviewer found that a hearing aid is a wearable sound-amplifying device that is intended to compensate for impaired hearing. Hearing aids are usually programmed to address an individuals degree of hearing loss across sound frequencies to improve speech intelligibility. Additionally, hearing aids may be coupled acoustically or wirelessly to external electronic products such as televisions, MP3 players, and telephones. A hearing health professional such as an audiologist or a hearing aid dispenser should program and optimize performance of hearing aids with more complex features. Based on the records provided for review, this patient with sensorineural hearing loss, meets the criteria for an assistive device. However, there is a lack of documentation provided in the medical records to support the need of the upgraded hearing aid device for the degree of hearing impairment noted on the hearing tests provided for review.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a fifteen year-old female with an eating disorder and bipolar disorder are requesting coverage of psychiatric residential treatment services.Reviewers Findings:  The reviewing physician found that it appears the patient had made sufficient gains that would have allowed segue to a lesser level of care. The reviewing physician found that the Health Plan denial should be partially overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement and prospective authorization and coverage for edaravone. Findings: The physician reviewer found that Radicava is U.S. Food and Drug Administration (FDA) approved for patient with ALS. Although the evidence for the benefit of Radicava has been shown in patients with early ALS, as defined in the pivotal trial, there is a lack of rationale demonstrating that the population evaluated in that trial is biologically distinct from the greater ALS population. Moreover, the FDA approved Radicava for ALS patients without any restriction. Therefore, treatment with Radicava is clinically indicated for this patient. All told, edaravone (Radicava) provided was and 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 medication at issue was and 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 and is actively practicing. One Reviewer is board certified in neurology 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 63-year-old female enrollee requested authorization and coverage of the Vest Airway Clearance System. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees bibasilar bronchiectasis. 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Orencia 125 mg/mL injection pen.According to the 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis, the addition of biologic disease-modifying antirheumatic drugs (DMARDs) (i.e., Orencia) or targeted synthetic DMARDs (i.e., Kevzara or Xeljanz) is recommended when escalating therapy to optimize rheumatoid arthritis disease control. The guideline also indicates that there is no recommendation for a targeted synthetic DMARD over a biologic DMARD. Either drug class is an acceptable next-line agent when escalating therapy to optimize disease control. In this case, the patient still has disease activity despite being on maximum methotrexate. There is sufficient support for the requested medication in this clinical setting. Therefore, Orencia 125 mg/mL injection pen is medically necessary for 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 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: Overturned

The patient is a 51-year-old female with severe allergies to inhalants. The patient has been on Allegra and Rhinocort AQ (nasal steroid) for two years. Previous medications tried and failed included Zyrtec, Claritin, Clarinex, Beconase, Nasonex, and Flonase. The submitted clinical notes indicate the patient received a prescription for a three-month supply of Allegra 180 and Rhinocort AQ in October 2002. In October 2003, a three-month supply with two refills (nine-month supply) was prescribed. The patients pharmacy records shows prescriptions for Allegra and mometasone (nasal steroid) in November 2003 and for Allegra in January 2004. In June 2004, a new prescription for Singulair was requested. The patient has requested authorization for the addition of Singulair to her regimen based on a positive response to its combination with Allegra and Rhinocort AQ. The Health Plan has denied the request on the basis that Singulair is not medically necessary for treatment of the patients allergies.Review of the submitted clinical notes indicates that a nine-month supply of Rhinocort AQ was ordered in October 2003. In spite of treatment with standard therapies this patient has not responded well. The patients provider notes the patient experienced a positive response to the addition of Singulair. In light of the patients response to Singulair and the failure of other medications including intranasal steroids, Singulair is medically appropriate and indicated for treatment of this patients allergies. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Urgent Care
Decision: Upheld

A 50-year-old male enrollee has requested urgent care services.  Findings:  The physician reviewer found that this patient had a recurrence of a chronic respiratory problem for which he had treatment available to him at home in the form of amoxicillin.  He had already started himself on that therapy, and based on the clinical documentation his primary reason for presenting to the urgent care was to obtain a refill for amoxicillin. The patient indicated he still had a few pills left at the time he presented to the urgent care center. He was not febrile, was not short of breath, did not have chest pain, and had a normal physical exam including normal oxygen saturation on room air.  A prudent layperson in this situation would not have thought that immediate medical treatment was necessary to prevent serious deterioration of health, injury or complication of an existing condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings:  Three physician reviewers found that despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantage it brings radiologists interpreting mammograms especially in women with dense tissue such as the patient under review. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in diagnostic accuracy compared to two-dimensional (2D) imaging alone. Thus, the addition of tomosynthesis to the usual 2D protocol was likely of greater benefit to the patient than had the exam been done with 2D imaging only.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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for OxyContin 30 mg three times a day. The Centers for Disease Control and Prevention (CDC) guidelines state that when opioid therapy is used, a patients regimen should include nonpharmacologic therapy and nonopioid pharmacologic interventions. Additionally, the CDC noted that, Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. The American Society of Interventional Pain Physicians (ASIPP) guidelines recommend providers to establish physical diagnosis and assess pain levels and disability to support medical necessity of treatment with opioids. In this case, the patient has chronic pain involving multiple areas. The records document that the patient has been treated with multiple forms of opioid medications in the past with poor effect. The provider noted that the patients pain has been stable on OxyContin with effective pain relief rated as 2/10 from his baseline pain rated as 10/10. His urine toxicology and Controlled Substance Utilization Review and Evaluation System (CURES) reports have been consistent with his therapeutic regimen. Furthermore, the provider reported that there is no evidence of adverse drug reactions or aberrant behavior identified. The providers documentation is consistent with the guidelines from the CDC and ASIPP for the safe prescribing of opioid therapy. Given this support, the requested OxyContin 30 mg three times a day is medically necessary for 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 anesthesiology with subspecialty certification in pain management 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 residential treatment center services. The progress notes indicate that the treatment team had recommended a partial hospital program in early June 2018. Since this recommendation, the patient had a serious overdose. The patient has a history of nonadherence to treatment and has tried other levels of care according to the records. Due to the patients apparent recent suicide attempt, outpatient or partial hospital program treatment levels of care are not likely to be safe or effective.The American Association of Community Psychiatrists Level of Care Utilization System is indispensable in determining necessary level of care for adults. In terms of risk of harm, the records support a score of 4 due to her recent suicide attempt. With regards to functional status, the records support a score of 4 due to poor overall daily function. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 1 due to overall medical stability and no substance abuse issues. With regards to level of stress of the recovery environment, the records support a score of 3 due to family discord. In terms of level of support of the recovery environment, the records support a score of 2 due to family support. In terms of treatment and recovery history, the records support a score of 5 due to minimal past treatment response. In terms of engagement and recovery status, the records support a score of 4 due to inaccurate symptom reporting in treatment and associated poor insight. Thus, the patient has a composite score of 23. This score correlates with residential treatment. Therefore, the requested residential treatment center services are 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 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: Upheld

The patient has requested authorization and coverage for bilateral eyelid revision surgery. Based on the patients history and diagnoses, additional eyelid surgery would not improve the patients ptosis related to myasthenia gravis. Similarly, the brow scars from previous surgery would not be improved with additional surgery. There is a lack of evidence in the medical record that this patient has undergone a thorough ophthalmological evaluation supporting the need for additional surgery. Given these findings, the requested bilateral eyelid revision surgery is not medically necessary for 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 board certified in ophthalmology 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.