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

A 53-year-old male enrollee has requested a minimally invasive mitral valve repair procedure (CPT 33430) for the treatment of his severe mitral valve regurgitation and mitral valve prolapse. Findings:  The physician reviewer found that the patient requires a mitral valve repair. Further, it is well supported in the medical literature that patients who are candidates for a minimally invasive approach have excellent outcomes, less pain, faster recovery, and fewer complications than with open approaches. The medical literature concluded that, long-term outcomes after minimally invasive mitral repair are excellent and equivalent to results achieved with sternotomy. All told, the requested minimally invasive mitral valve repair procedure (CPT 33430) is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Saxenda for treatment of the enrollees chronic weight management. Findings:  The physician reviewer found that Saxenda is approved by the U.S. Food and Drug Administration as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index of 30 kg/m2 or greater (obese) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition, such as hypertension, type 2 diabetes mellitus, or dyslipidemia. The recommended approach to weight loss with pharmacological management of obesity is for a patient to receive counseling on diet, lifestyle and goals for weight loss. Medications such as Orlistat are considered first line treatment.  Saxenda is an alternative option for overweight or obese patients with type 2 diabetes mellitus. The patient is documented as weighing 170.2 pounds and is 63.5 inches tall with a resulting BMI of 29.7.  The laboratory studies that were performed on 5/26/16 noted normal glucose and cholesterol levels with an HgbA1C at 5.7. 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.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old male enrollee has requested additional speech therapy for the treatment of the enrollee, who is status post stroke. Findings:  The physician reviewer found that the literature supports the efficacy of speech therapy for the treatment of aphasia in both the acute and chronic phases of recovery. According to studies, speech therapy sessions should be intensive and provided over prolonged periods of time in order to optimize recovery of function. The patient is continuing to benefit from speech therapy and continuing to demonstrate recovery of his communication skills. This is consistent with what is often seen in post-stroke aphasia, as recovery often continues two or more years following stroke. Therefore, speech therapy services should be continued as long as the patient continues to respond to the treatment and continues to achieve targeted goals. Additional speech therapy is medically indicated for this patient given his significant residual expressive aphasia following CVA as well as his capacity for continued improvement.
Appeal type: Medical Necessity
Decision: Upheld

The spouse of a 65-year-old male has requested skilled nursing facility services for treatment of the enrollees lung cancer with metastases to the brain.  Findings:  The physician reviewer found that the submitted records indicate that the patient has widespread metastatic cancer. As of the said date, therapy was discontinued.  There have been no significant active medical issues requiring inpatient hospital care since the said date, per the submitted documentation. The patient has not required skilled nursing services such as complex medication provision or complex wound care during this time. He has been at custodial care, which would include services such as, but not limited to, help with walking, getting in and out of bed, bathing, dressing, eating, taking medication, bowel or bladder care, and routine wound care. Ongoing hospitalization would not have been expected to significantly improve the patients health or functional outcomes.  All told, as of the date in question, the patients needs have been custodial in nature.  Thus, skilled nursing facility services during this period were not and are not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 58-year-old female enrollee has requested Botox injections for treatment of her migraine headaches. Findings:  Two physician reviewers found that this patient has chronic migraines. Review of the submitted clinical information indicates the patient has failed almost all of the FDA-approved preventive agents. As such, continued treatment with standard pharmacologic agents is not likely to be of benefit. Botox injection therapy has been shown in several studies to be effective in the treatment of chronic migraine. Given that the patient has exhausted standard options, treatment with Botox is a medically reasonable and appropriate treatment option.
Appeal type: Experimental/Investigational
Decision: Overturned

A 58-year-old male enrollee has requested electronic brachytherapy for treatment of his basal cell carcinoma of the right cheek.  Findings:  Two physician reviewers found that radiation is within accepted standards as an alternative to surgery in this clinical setting. More importantly, there is a rationale as to why electronic brachytherapy was used as opposed to standard radiation, as the superficial nature of the radiation would better protect the underlying tissue in the treatment of this patients disease. While electrons would likely be the most commonly used approach, this would not provide adequate protection to the underlying buccal mucosa. In summary, the records and medical literature indicate that the electronic brachytherapy provided was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 31-year-old male enrollee requested authorization and coverage of disposable self-catheters or intermittent catheters. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees paraplegia.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer partially overturned the Health Plans denial on the basis that the requested equipment is medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 31-year-old female enrollee has requested gastric bypass surgery for treatment of her obesity. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The medical records note a body mass index of greater than 45.  She is status post laparoscopic gastric band procedure with subsequent band removal.  The medical records do not support the medical necessity of the requested gastric bypass surgery in this clinical setting.  The records do not include an updated dietary or behavioral evaluation.  Although the patient was screened in the year indicated, it is important to ensure that the patient currently is an appropriate candidate for the procedure.  All told, the requested gastric bypass surgery is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old male enrollee requested authorization and coverage of a laparoscopic radical prostatectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees 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 procedure is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for RT300 functional electrical stimulation (FES) cycle therapy system.Findings:  Two out of three physician reviewers found that there is sufficient support for the requested device in this patients case. Once a patient has sustained a spinal cord injury and is stabilized, lower extremity mobilization can be achieved by use of an ergometer powered by a patients own muscle strength evoked by functional electrical stimulation (FES). Electrical stimulation of the peripheral and central nervous system is commonly used for rehabilitation and management of complications following spinal cord injury. Electrical stimulation may improve the functional status and quality of life of individuals with spinal cord injuries. The medical evidence indicates that the benefits of FES ergometry include increases in lean body mass with a decrease in whole body fat content, increases in muscle endurance, increases in muscle output, improved oxygen uptake, positive changes in spasticity and increases in joint range of motion. Thus, the requested RT300 FES cycle therapy system is likely to be superior over other treatment options.Final Result: The reviewers determined that the requested device 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: Physician reviewers 1, 2 and 3 are board certified in physical medicine and rehabilitation 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

A 62-year-old female enrollee requested reimbursement for a sacroiliac joint injection.  The Health Plan denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees back pain. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the services at issue. The patients physical examination indicated pain and tenderness extending from the sacroiliac joint.  The MRI excluded other causes of her pain, such as lumbar radiculitis. Additionally, the patient had tried non-steroidal medications, narcotics and antidepressants, all of which did not relieve her pain.  Her pain was reduced only temporarily with rest. Dreyfuss and colleagues noted that diagnosing sacroiliac joint-mediated pain was difficult because the presenting complaints were similar to other causes of back pain.  The authors noted that radiographic and laboratory tests primarily help exclude other sources of low back pain, while MRI, CT and bone scans of the sacroiliac joint cannot reliably determine whether the joint is the source of the pain.  Dreyfuss and colleagues concluded that controlled analgesic injections of the sacroiliac joint are the most important tool in the diagnosis.  Zelle and colleagues assessed the clinical presentation, diagnostic testing and treatment options for sacroiliac joint dysfunction via a systematic literature review. They found that a reliable examination technique to identify the sacroiliac joint as a source of low back pain is pain relief following a radiologically-guided injection of local anesthetic into the sacroiliac joint.  In this patients case, she failed to receive relief with conservative therapy, and the injection served to be both diagnostic and therapeutic.  The medical literature supports the services at issue in this clinical situation.  All told, the sacroiliac joint injection was medically necessary in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for the medication Exondys 51. Findings:  Three physician reviewers found there is sufficient support for the requested medication in this clinical setting. The U.S. Food and Drug Administration has approved eteplirsen for the treatment of patients with exon 49-50 deletion. A study showed that the deterioration in respiratory muscle function with eteplirsen treatment as measured by the forced vital capacity was half that seen in the natural history of patients with Duchenne muscular dystrophy. This patient has been followed by a neuromuscular specialist, and has documented stable upper extremity and lower extremity function. Maintenance of these functions are significant for independence and quality of life. In this patients case, Exondys 51 is likely to be more effective than other treatment options. Final Result: The reviewers determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology with special qualification in child neurology 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: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee has requested cold/compression therapy for the treatment of the enrollee, who is status post knee surgery. Findings:  Two physician reviewers found that there is insufficient scientific literature documenting significant clinical benefit of cold/compression therapy over standard ice packs following outpatient knee surgery. The medical literature does not demonstrate an advantage of cold/compression therapy over ice packs in terms of functional outcomes and clinical assessments at each follow-up examination. Conflicting studies with relatively short-term follow-up exist in the literature. There is a lack of high quality demonstrating that cold therapy is better than intermittent ice pack use with respect to improving mid-term and long-term functional outcomes. As such, cold/compression therapy was not likely to be more efficacious for this patient than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets 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. Applying ASAM criteria, the RTC services were medically necessary for treatment of this patient. The patient has a treatment history of failure and rapid relapse on drugs and alcohol following discharge. He has been unable to stop using substances on his own or with prior treatment. The patient is at elevated risk with continued substance abuse given his diagnosis of hepatitis C and promiscuous behavior while intoxicated. The patients mental status was overall sufficient to permit participation. He was initially unable to consent to treatment due to psychosis. Treatment with Risperdal and Invega Sustenna were an integral part of patients treatment given his continued and progressive psychotic symptoms as noted by active persecutory delusions and hallucinations. He was later able to relate his desire to change despite his struggles with inattention, distraction, and hyperactivity in groups. The patient demonstrated limited insight into his need for continued treatment. The records document that the patient has shown limited understanding on the effects of his substance use on coping and functioning. The patient has been at imminent danger of relapse as result of a crisis. The patients parents have enabled his behavior. The patient has been at risk of returning to dangerous impulsive behavior in the context of poor coping, low premorbid functioning, and delusions. The patients recovery environment was too chaotic for the patient to succeed in his treatment goals. His family enables his addiction and his aggression towards them leads them to be fearful. Given these findings, RTC level of care services were medically necessary for treatment of this patient. 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: Urgent Care
Decision: Upheld

The parent of a 1-year-old male enrollee has requested  emergency services for treatment of the enrollee's complaints of coughing.  Findings:  The physician reviewer found that the issue in this case is whether a prudent person in the patients circumstances would believe he or she was experiencing an emergent medical condition requiring emergency medical services. An emergent  medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part.  This case does not meet the prudent layperson criteria for emergent care. The patients acute symptoms of watery eyes and a runny nose do not constitute an emergency. The cough had been going on for four months and was not associated with worrisome acute symptoms like wheezing or fever. The laboratory tests and chest x-ray did not reveal evidence of significant disease. The treatment rendered (intramuscular Decadron) was non-specific and not needed emergently. In addition, the providers final clinical impression was that of a benign URI. In addition, there was no evidence that the patient was in pain. For these reasons, the services rendered in the ED could have been rendered at a later time by his primary care provider or a pediatric clinic without any risk to the patient.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old female enrollee has requested Provigil for the treatment of her excessive daytime sleepiness. Findings:  The physician reviewer found that this patient has a stated diagnosis of narcolepsy with cataplexy, which is a primary indication for Provigil. A multiple sleep latency test is not required to diagnose narcolepsy if the patient has cataplexy. However, no appropriate documentation was submitted to substantiate this diagnosis. Overall, there are no records confirming narcolepsy with cataplexy or shift work sleep disorder to justify coverage for Provigil at this time.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient hospital services at Los Robles Regional Medical Center. Findings:  The physician reviewer found that the patient was admitted with a history of gastroesophageal reflux disease (GERD) and ongoing chest and neck discomfort. He had normal electrocardiogram (EKG) results, negative troponins, and diagnostic imaging did not show aortic dissection. The patient was treated for gastrointestinal symptoms and hypertension, with symptoms improving rapidly, and he was ready for discharge the following day. In this clinical setting, the patients low cardiac risk could have been managed at a lower level of care.    Therefore, inpatient hospital services at Los Robles Regional Medical Center were not medical necessary for the treatment of this patient.Final Result: The reviewer determined that 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 internal medicine with sub-specialty certification in cardiovascular disease 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 male enrollee has requested immunosupport therapy for the treatment of his metastatic testicular cancer. Findings:  The physician reviewer found that the immunosupport therapy program offered consists of a combination of high-dose intravenous nutritional supplementation, the use of hyperbaric oxygen chamber, far-infrared sauna, acupuncture, and various oral supplements coupled with lifestyle modification. There is no scientific evidence that any of the treatment modalities included in this immunosupport program are of significant benefit in the treatment of cancer, or in boosting the immune system. No peer-reviewed studies have been published demonstrating that these interventions are efficacious in this setting. In the absence of such data, the clinical value of the disputed services has not been established.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for the medication Dupixent. In this patients case, the diagnosis is not clear. The records suggest that the patient has contact dermatitis that is poorly controlled, and this diagnosis has not been addressed fully in the enclosed documentation. Avoidance of the contact allergens would be the first step, and then non-pharmacologic interventions and counseling on this would be medically appropriate. The records do not clearly demonstrate that the patient has atopic dermatitis, and Dupixent would be more appropriate for atopic dermatitis, not contact dermatitis. Therefore, the requested medication Dupixent is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.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.