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

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment center services for treatment of her behavioral health conditions. Findings: The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting.  The patient had a concerning history which dominated multiple functional domains.  The patient had been unable to achieve any meaningful sustained sobriety in an extended period of time.  Further, the patient had significant psychiatric comorbidity in the presence of acute psychosocial stressors.  Based on the medical records, discharge to a less restrictive setting would have been premature and resulted in undue morbidity, prompt relapse and re-admission. The patient was noted to be gaining insight and motivation for improvement, but still struggling with dysphoria, self-defeating behavioral urges and negative self-talk.  The records demonstrate that the patient had not consolidated the treatment gains necessary to success in a less restrictive setting.  The services provided during the timeframe at issue were for active treatment, and reasonably expected to improve her condition and prevent a more serious episode of illness.  All told, residential treatment services were medically indicated for the 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 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 BRAF genetic testing for evaluation of his medical condition.  Findings: Two physician reviewers found that there is support for the services at issue in this clinical setting.  There is published data from a large retrospective trial that the presence of the BRAF mutation provides additional prognostic information with regards to cetuximab treatment.  The testing performed in this case was standard care.  Therefore, BRAF genetic testing performed was likely to have been more effective than other modalities for evaluating this patient.   Final Result: Two 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:   One reviewer is board certified in internal medicine and is actively practicing.  Two reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Overturned

A 53-year-old male enrollee has requested emergency room services for the treatment of his headaches and neck pain. Findings:  The physician reviewer found that on exam, the patient was found to be in moderate distress, had bilateral frontal sinus pain, tearing of both eyes and sinus pressure. He was noted to be immunosupressed due to treatment with interferon. An immunocompromised state may predispose the patient to more severe illnesses and disorders. In these cases, patients must be worked up more aggressively than immuno-competent patients who present with the same symptoms. Lab testing was significant for elevation of liver function tests, thrombocytopenia (low platelets), and a low potassium. The patients condition was noted to improve.The symptoms of severe headache and neck muscle tightness in an immunocompromised patient are consistent with potentially life-threatening conditions, including meningitis, subarachnoid hemorrhage and other cerebral disorders. It is reasonable for a prudent layperson to access emergency medical care for such symptoms. The patients symptoms did met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old male enrollee has requested for implantation of an auditory osseointegrated implant system for treatment of his acoustic neuroma. Findings:  The physician reviewer found that the patient is an excellent candidate for the BAHA procedure and does appear to meet the criteria set, as he is five years of age or older with unilateral single-sided deafness with hearing in the contralateral ear that meets the stated definition for normal. The fact that he is nearly deaf in the right ear is not a contraindication to the implantation procedure and in fact makes him a qualified candidate for a BAHA device.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a positron emission tomography/computed tomography (PET/CT) scan for evaluation of the enrollees rectal cancer. Findings:  The physician reviewer found that there is some debate concerning the use of PET/CT as a surveillance tool in colorectal cancer cases. However, the current literature tends to favor this technique particularly in the post-operative patient with surgical deformity and scar formation as the normal anatomic planes are obscured in this scenario making conventional imaging studies less advantageous. Recent articles support the use of PET and the calculation of the standardized uptake value (SUV) as a physiologic assessment of abnormal tissue and a differentiator between post-operative scar and tumor. Moreover, since this patients chemotherapy ended, a PET/CT will serve as a post treatment baseline. For these reasons, the requested PET/CT scan is medically necessary for evaluation of this patients rectal carcinoma. Final Result: The reviewer determined that the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 48-year-old male enrollee requested a 12-week course of Harvoni 90/400 mg tablets for medical treatment of his hepatitis C virus.  Findings:  Two physician reviewers found that in treatment-naive patients, therapy is recommended with Harvoni for 12 weeks. In addition, Harvoni is U.S. Food and Drug Administration (FDA) approved for all patients with chronic genotype 1 hepatitis C regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). Additionally, treatment of patients before they progress to F3 or F4 fibrosis is advantageous. According to the article by Younossi and colleagues, the initiation of HCV therapy at an earlier disease stage yielded substantially fewer cases of decompensated cirrhosis, hepatocellular carcinoma, liver transplant and HCV-related death. Based on the medical literature and clinical guidelines, Harvoni is medically necessary for treatment of this patients medical condition of HCV.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 56-year-old woman who has requested authorization for palatopharyngoplasty. The patients provider indicates the patient has a history of daytime sleepiness and an elongated uvula and soft palate. The submitted information does not include any other clinical history or physical information regarding the patient. The patient underwent polysomnogram evaluation that revealed marked reduction in sleep efficiency with total REM sleep time being reduced to half an hour. Except for during this short period of REM, the patients AHI was 4.4. During REM only, AHI was found to be 25. Significant increase in periodic limb movement was noted. There was also notation of the presence of snoring. There were no findings of obstructive sleep apnea.The patients provider indicates the patient cannot tolerate CPAP due to claustrophobia. Therefore, the patients provider has recommended palatopharyngoplasty. The Health Plan indicates that the requested procedure is not medically indicated as it is not likely to be effective for treatment of the patients condition.The procedure of palatopharyngoplasty is appropriate for treatment of primary snoring, for which its efficacy is stated to be 80-90 percent. The requested procedure is also indicated for patients diagnosed with obstructive sleep apnea who have anatomy conducive to this procedure and who have failed a trial of CPAP or BiPAP. The efficacy of palatopharyngoplasty for treatment of obstructive sleep apnea is generally stated to be around 50 percent. Although this patient does have a snoring problem, there is no documentation of actual obstructive sleep apnea. Palatopharyngoplasty is not medically indicated in the absence of documented evidence of obstructive sleep apnea. 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: Overturned

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested residential treatment center (RTC) services for treatment of the patients behavioral health condition.  Findings:  The physician reviewer found that the RTC services were and are medically necessary for treatment of the patients medical condition. According to the American Psychiatric Association (APA) treatment guidelines for the treatment of patients with this diagnosis, the criteria regarding care at the RTC level is the motivation that the patient has to recover, including cooperativeness, insight and ability to control obsessive thoughts. Another important factor is the amount of structure that is needed for eating and gaining weight and preventing compulsive exercising. The APA guidelines also emphasizes that before a patient is discharged from inpatient level of care, the patient needs to learn to maintain a healthy weight prior to discharge. If the patient is discharged before this learning occurs, the patient is likely to immediately decrease their caloric intake to excessively low levels and lose weight. Of significant importance in determining readiness for discharge is the ability of family to continue her program as an outpatient. The documentation submitted for review indicates that the family is not yet ready to provide adequate structure at home. As such, this patient continues to meet criteria for RTC level of care. Considering the clinical documentation submitted and national guidelines, the RTC services were and are medically necessary for treatment of the patients behavioral health condition.  Final Result: The reviewer determined that the services at issue 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 with sub-specialty certification in child and adolescent 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

A 51-year-old female enrollee requested authorization and coverage of a power-operated vehicle. The Health Plan denied the request indicating that the requested equipment is not medically necessary to assist with the enrollees mobility.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: The patient has requested authorization and coverage for Euflexxa injection series (J7323) in the right knee. An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. Guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where everything else has been tried and the options are limited. In this patients case, the options are limited. The patient has tried and failed NSAIDs, physical therapy and a home exercise program. However, she has not tried viscosupplementation. The medical evidence indicates that viscosupplementation is beneficial for chondromalacia of patella in light of the anti-inflammatory, analgesic, and chondroprotective action of hyaluronic acid. Furthermore, it has been shown to be safe and effective in the treatment of pain related to patellar chondropathy. Therefore, the requested Euflexxa injection series (J7323) in the right knee is medically necessary for 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 orthopedic surgery 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: The patient has requested authorization and coverage for computed tomography (CT) scans. Findings:  The physician reviewer found that this patient underwent treatment for cancer. However, he remains at high risk for recurrence. According to the National Comprehensive Cancer Network (NCCN) guidelines for mantle cell lymphoma, follow-up is recommended every three to six months for the first five years. This follow-up should include diagnostic tests and imaging using the same modalities performed during work-up. This patients last reported CT scan was over six months ago. Given his risk for recurrence, the requested CT scans are medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for evaluation 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 certifications in medical oncology and hematology 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 59-year-old female enrollee requested authorization and coverage of a DEXA scan. The Health Plan denied the request indicating that the requested DEXA scan is not medically necessary for evaluation of the enrollees bone density.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested DEXA scan is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A female enrollee requested transcatheter insertion of Amplatzer patent foramen ovale (PFO) closure device for medical treatment of her patent foramen ovale. Findings:  Two physician reviewers found that there is sufficient support for the requested services in this clinical setting.  The medical evidence has demonstrated a beneficial effect in the prevention of recurrent neurologic events with PFO closure.  Considering the association of cryptogenic stroke in addition to migraine in this patients case, the requested services are likely to be of greater benefit over standard medical therapy, which would include lifelong systemic anticoagulation.  In sum, transcatheter insertion of Amplatzer PFO closure device is likely to be more effective than other available alternatives.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a single photon emission computed tomography (SPECT) scan for evaluation of his Parkinsons disease. Findings:  Three physician reviewers found that it has been well established in the current peer-reviewed medical literature that functional imaging in Parkinson disease is much more beneficial than static imaging. In SPECT imaging, there is a measurement of dopamine terminal function sensitivity detection in both symptomatic and patients at risk for Parkinsons disease and associated dementia versus Alzheimers dementia. Such differentiation is important in the treatment planning of the two diseases. Static imaging such as computed tomography (CT) or magnetic resonance imaging (MRI) does not incorporate the physiology of such diseases. The use of SPECT allows the evaluation of the physiology of the substantia nigra for striatal dopamine deficiency, the hallmarks of Parkinsons disease and to exclude other causes of tremors including dystonic tremors and those associated with exogenous agents such as dopamine receptor blocking drugs. Functional imaging can detect the presence of dopaminergic dysfunction, cortical hypometabolism and amyloid pathology in dementia thus aiding in their classification which in turns helps planning for treatment. This information is not available in static imaging such as MRI. For these reasons, the requested SPECT scan is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: All three reviewers determined that the requested service is 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 reimbursement and prospective authorization and coverage for dual diagnosis 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 including: (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. For dimension 1, the patient has demonstrated moderate CIWA scoring with symptoms including nausea, sweating, tremor as well as auditory and visual disturbance. The patient reported headaches, agitation, and a lack of motivation. The patient satisfies dimension 2 given his history of human papillomavirus (HPV), which has been untreated, with associated abdominal pain and nausea. For dimension 3, the patient has comorbid panic disorder and depression. The records support dimension 4, as the patient has been using for over 10 years and endorsed his last use was on the way to the RTC. The patient reported cravings, mood swings, irritability, and impulsivity. The patient has low accountability and is willing, but not yet able or ready. For dimension 5, the patient has symptoms of depression and anxiety that he has tended to self-medicate with substances and continued cravings. For dimension 6, the patient has limited support and structure outside of RTC has tended to isolate in bed. The patient requires a safe and stable living environment in order to develop his recovery skills and qualifies for ASAM Level III treatment similar to what patient has received at the current facility. Given the severity of the patients illness, the dual diagnosis RTC services were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue 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 with expertise in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a dermatology consultation for evaluation of the enrollees rosacea. Findings:  The physician reviewer found that Rosacea is a common chronic inflammatory disorder of the facial skin characterized by periods of exacerbation, remission and possible progression. The major subtypes include erythemato-telangiectatic rosacea and papular-pustular rosacea. Individual subtypes are likely a result of different pathogenic factors and respond best to different therapeutic regimens. Rosacea is a polymorphic disease precipitated by many causes including genetic, vascular, immune-mediated, emotional, environmental, and infectious factors. The non-pharmacologic approach to therapy is adequate skin care, trigger avoidance and photo-protection. In addition, there are several topical, herbal, systemic and light based therapies available. Since biopsy of a typical untreated lesion may be required to differentiate rosacea from seborrheic dermatitis, the referral to a dermatologist was appropriate. Final Result: The reviewer determined that the service at issue was medically necessary for evaluation 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.