Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Overturned

The parent of a six-year-old female enrollee has requested  for emergency services for treatment of the enrollees abdominal pain and vomiting.  Findings:  The physician reviewer found that She had recently been inpatient with right upper lobe pneumonia, fever and abdominal pain, and to rule out appendicitis. During that admission, she was noted to have bladder distention and urinary retention of unclear significance. Appendicitis was ruled out by the surgical service. The patient was discharged to complete a course of oral antibiotics. She was taken to the pediatricians office because of nausea, vomiting, and abdominal pain. The vomitus was non-bloody at that time. Her examination was remarkable only for tenderness on abdominal exam, without rebound or guarding. Tums were recommended for presumed gastritis and the family was instructed to complete the course of antibiotics. The patient was subsequently brought to the ED with increased abdominal pain and new onset of blood-streaked emesis. Physician history revealed vomiting twice per day for two weeks, with blood-streaked emesis on the day of presentation. Periumbilical pain was noted. Review of symptoms revealed a six-pound weight loss over the past 2 weeks, throat pain, decreased activity, decreased oral intake, and decreased urination. Physical examination was significant for pharyngeal erythema, slightly dry mucus membranes, decreased heart rate with regular rhythm and paraspinal tenderness. An acute abdominal series was negative for intraabdominal pathology and CT of the head was normal. Laboratory studies were remarkable only for a CO2 of 19 (mildly decreased), and a urine dip revealed a specific gravity of 1.010, with trace ketones and 2+ protein. The patient was given a fluid bolus, and admitted for evaluation of persistent vomiting. The patients symptoms met prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and a child with worsening abdominal pain and blood-streaked emesis would reasonably expect the absence of emergency care to jeopardize the patients health. The parents observed the patient to be in severe pain and dizzy and the patients blood pressure was less than the 50th percentile for age. Laboratory results support a diagnosis of mild dehydration and there was a recent six-pound weight loss. The patient was admitted to inpatient care directly from the ED.
Appeal type: Urgent Care
Decision: Upheld

A 29-year-old female enrollee has requested emergency services for the treatment of her back pain.  Findings:  The physician reviewer found that an emergency is defined as the sudden onset of symptoms of such severity that a prudent layperson would believe the lack of immediate medical attention would endanger her health. This patients symptoms had been present for two weeks. They were not sudden in onset. The patient also had prior history of similar back pain, making it unlikely that a prudent layperson would believe an emergency existed. This patients symptoms do not meet criteria for an emergency.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested mental health inpatient hospitalization for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The patient was diagnosed with a serious mental illness that impacts mood and cognition and is associated with functional impairment across multiple domains, poor clinical outcomes and heightened risk of suicide.  Despite good family support, efforts to engage in age-appropriate community activities while consolidating the gravity of her psychiatric diagnosis, and treatment with complex pharmacotherapy, one of which is delivered via long-acting injection, the patient was clinically depressed and endorsing suicidality.  The patient was engaged in active treatment during the entire hospital stay including aggressive medication management, discharge planning and aftercare involving family, group and milieu therapies, and other standard interventions afforded by the inpatient setting.  During the disputed timeframe, the acute inpatient setting remained reasonably expected to improve the patients condition while preventing a more serious episode of illness.  All told, mental health inpatient hospitalization  was 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

A 53-year-old female enrollee has requested genetic testing for HNPCC for evaluation of her colon cancer.  Findings:  Three physician reviewers found that the hallmark of HNPCC is defective DNA mismatch repair which leads to MSI-H tumors. There are other cancers that may occur in patients with these abnormalities. Given this patients individual history and possible personal and familial consequences, it is appropriate to perform the requested genetic testing. In this patient, there is a reasonable possibility for a Lynch syndrome carrier diagnosis and the requested testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard testing.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. The Health Plan has denied this request indicating that the services at issue are not medically necessary for treatment of the enrollees substance abuse. At issue in this case is whether the requested residential treatment center level of services provided were medically necessary for treatment of the patients behavioral health condition. The American Psychiatric Association treatment guidelines for substance use disorders recommend that residential treatment or similar care higher than outpatient is indicated for patients who: do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use. Lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. The patient requires safe and stable living environments in order to develop their recovery skills thus qualifying for treatment. Rehabilitation is the essential component that should follow detoxification to help the patient maintain sobriety and reduce risk of relapse. Given the severity of the patients illness and his continuing to have symptoms of restlessness/cravings through his stay residential; treatment was in accordance with generally accepted standards of medical practice and clinically appropriate for the patient's illness and therefore medically necessary.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: Medical Necessity
Decision: Overturned

A 43-year-old male enrollee requested authorization and coverage of laser stapedectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees hearing loss.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old female enrollee has requested inpatient mental health residential treatment services for treatment of the enrollees eating disorder, anxiety disorder, and depression.  Findings:  The physician reviewer found that the patient was superficial on the unit and not invested in treatment. Her provider increased the frequency of her anxiolytic medication.  She has yet to resolve the issues that prompted the admission or harmonize the family dynamics that undermined the home environment.  Discharging the patient under such circumstances would be inconsistent with contemporary practice standards as she would likely experience undue morbidity and likely require prompt readmission. The record reflects that the patient is receiving active evidence-based treatment consistent with the current practice guidelines and relevant peer-reviewed literature.  Although the patient is making progress in her therapies and medication management, she has not yet consolidated the treatment gains necessary to succeed in a less restrictive treatment setting.  All told, residential treatment is the appropriate treatment environment, which supports the inpatient mental health residential treatment services provided as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A fifty-six year-old female with metastatic rectal carcinoma is requesting authorization for Avastin and Erbitux.   The patient is currently receiving treatment with Camptosar, Avastin and Erbitux.Reviewers Findings:  The reviewing physician found that the submitted clinical records do not document the failure of second and third-line therapeutic regimens.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old male enrollee has requested robot assisted laparoscopic prostatectomy (Da Vinci) for the treatment of his prostate cancer. Findings:  The physician reviewer found that radical prostatectomy can be performed through an open incision as has been routine for the last several decades. In the last few years however surgeons have learned to remove the prostate laparoscopically with robot assistance which has increased the facility, speed, and safety with which this operation can be performed. There are now multiple centers with extensive experience performing robot assisted radical prostatectomy and the frequency with which it is performed has increased rapidly in the last few years. The outcomes for cancer cure and continence appear to be equal to the open procedure, but the blood loss and preservation of erectile function are better than with open surgery. It is anticipated that the Da Vinci robot will be used to perform more than 60% of the radical prostatectomies in the United States in 2009. It has become the standard of care for laparoscopic radical prostatectomy. By comparison, straight laparoscopy is difficult, technically challenging, and simply not as precise as the surgery when performed with the assistance of the Da Vinci robot which offers 3D depth perception, increased dexterity with the special tools, and seven degrees of range of motion instead of only four as with straight laparoscopy. In addition, the improved instrumentation makes the procedure easier, more precise, and faster.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested Benicar (olmesartan) for the treatment of her chronic Lyme disease. Findings:  The physician reviewer found that the medical records reveal little supportive evidence for either early or late stage Lyme disease. Additionally, the diagnosis of chronic Lyme disease is not supported by the scientific literature. Furthermore, standard treatment for late-stage Lyme disease is one month of intravenous ceftriaxone. There is no evidence that repeated or prolonged courses of antibiotic have any clinical efficacy. Although the theory of creating a 1,25-dihydroxyvitamin D deficiency and using an angiotensin-II receptor blocker to treat Lyme disease is intriguing, it is unproven in the peer-reviewed literature. There is no proven role for the use of Benicar, at any dose, in the treatment of Lyme disease. There are no clinical trials published in peer-reviewed journals that demonstrate the efficacy of this treatment regimen. Moreover, high doses of Benicar can cause significant side effects and it is not FDA-approved for this indication. As such, there is no medical necessity for the use of Benicar in the treatment of Lyme disease in any stage.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old male, with idiopathic short stature, has requested authorization for growth hormone therapy.Reviewers Findings:The reviewing physician found that the information provided demonstrates the patient has benefited from the use of growth hormone therapy in the past and is likely to continue to experience positive results.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Orthovisc injection to the right knee for treatment of the enrollees moderate chondromalacia of the right knee.  The physician reviewer found that overall, the scientific evidence for the use of a repeat viscosupplementation injections series demonstrates that there may be continued improvement in some cases that otherwise would result in total knee arthroplasty. Pagnano and Westrich performed a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee. The authors concluded that repeat courses of the hyaluronans are safe and effective in the treatment of pain associated with osteoarthritis of the knee. In addition, a study by Turajane and colleagues concluded that repeated cycles of intra-articular sodium hyaluronate treatment was efficacious during a 54-month follow-up period in continuing to delay time for a total knee arthroplasty in patients with knee osteoarthritis. Considering the risk of complications with total knee arthroplasty, a repeat a series of Orthovisc injections is medically reasonable and appropriate. As such, the Orthovisc injection to the right knee is medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested service 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 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: Upheld

A male enrollee requested residential mental health and substance abuse treatment for medical treatment of his opioid dependence.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings optimize treatment gains.  The recent clinical documentation does not demonstrate the need for residential mental health and substance abuse treatment at this time.  Given the paucity of recent clinical records, the medical necessity of the requested services has not been established.  All told, the requested residential mental health and substance abuse treatment is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage to add intravenous (IV) morphine to the emergency treatment protocol for treatment of her migraine headaches. Migraine is a frequent chief complaint leading to presentation to acute care. Researchers have noted that while opioids are frequently used as a migraine abortive agent, evidence suggests that this is not the most effective agent and that it can lead to potential chronic migraine and other headache disorders including medication overuse headache. Several therapies have been compared with opioid analgesia and have shown to be superior, including, but not limited to, dihydroergotamine, ketorolac, butyrophenone, and phenothiazines. Additionally, researchers have found that there is evidence to suggest that opioid analgesia may decrease response to more appropriate migraine abortives such as triptans. Therefore, the addition of IV morphine to the patients emergency treatment protocol for treatment of her migraine headaches is not medically necessary for treatment of her medical condition.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 neurology 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

Nature of Statutory Criteria/ Case Summary:  The enrollees parent has requested  coverage for Nutramigen baby formula. A review of the records indicates the enrollee is growing well and gaining weight. Formula is noted to be Nutramigen 4 ounces very two to three hours. There is no documentation of allergies or rashes. Growth and development is appropriate. A referral request was for EF Ped Hydrolyzed/Amino Acid for symptoms of clay like stool, formula concern. Physician indicates tried Nutramigen and doing well, will refer for formula. A prescription by the provider was for Nutramigen. Per addendum, the mother indicated the enrollee gets a rash with Gentlease and Reguline.  According to the medical literature, the majority of children with cow milk protein allergy have one or more symptoms involving one or more organ systems, mainly the gastrointestinal tract and/or skin. If a cow milk protein allergy is suspected in a patient by a history and examination, then strict allergen avoidance is initiated. Typically a food challenge is recommended to confirm the diagnosis, provided that symptoms are not life-threatening.  For infants with a true cow milk protein allergy, a trial of an extensively hydrolyzed formula is recommended. There is insufficient evidence in the records of a milk protein allergy or failure to thrive. It was specifically documented that the enrollee had been gaining weight well and had no blood in her stool. There also was no documentation in the two physical examinations provided that supports the enrollee had a milk protein allergy. There were only two sentences in the addendum to the office visits, which recounted the parents report of a rash without a medical professionals confirmation of the nature or appearance of the rash. A rash may be a symptom of a milk protein allergy, but the medical reports do not demonstrate the cause of the enrollees rash here. A rash may also occur in a variety of non-allergic settings in infants. The medical literature indicates a milk challenge should be performed in non-life-threatening cases to confirm the diagnosis. It does not appear this had been done here. In addition, it is noted in the record that the enrollee was consuming Gentlease formula alongside Nutramigen, without rash documented in these notes.Final Result: The reviewer determined that the service at issue is not medically necessary for treatment of the enrollees condition. Credentials/Qualifications: The physician reviewer is board certified in Pediatric Gastroenterologyand 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam radiation therapy for treatment of her breast cancer. Findings:  Two physician reviewers found that there is a lack of medical literature to suggest that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques for breast cancer. A plan comparison was run between standard three-dimensional conformal techniques with photons versus intensity modulated proton therapy, and this showed a decrease in the heart dose. However, this comparison is not valid because the standard techniques to use in this setting when the heart dose cannot be achieved with three-dimensional conformal techniques is to utilize intensity modulated radiation therapy with photons (instead of protons). There is a lack of data submitted that suggests that treatment with proton techniques will be able to improve sparing of the skin, heart, and/or lungs compared to standard intensity modulated breast radiation with photon techniques. Consensus group guidelines do not support the use of proton therapy in this setting. In the vast majority of cases, intensity modulated radiation with photons is able to achieve an acceptable cardiac dose in left sided breast cancer compared to three-dimensional conformal techniques. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in radiation oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old male enrollee has requested reimbursement for cryosurgical ablation therapy for treatment of the enrollees renal mass.  Findings:  Three physician reviewers found that the patient was found to have a renal mass during imaging for an unrelated urologic complaint. As a result of a high suspicion of malignancy based on the radiographic interpretation, he underwent needle biopsy which revealed renal cell carcinoma (RCC). He was treated with cryoablation of the mass and has requested coverage for this therapy. The patients Health Plan has denied reimbursement as they consider cryoablation to be investigational for treatment of RCC. There is a paucity of scientific data demonstrating that cryotherapy is the treatment of choice in an otherwise healthy patient when there is no evidence of extenuating circumstances such as diminished renal reserve or marginal health which would make surgery unusually risky. Current data suggest that partial nephrectomy offers greater local control of RCC (Rodriguez, et al). Consistent with these findings, partial nephrectomy remains the option supported as safe and effective in the long-term, and the cryoablation performed in this patients care was not likely to be more beneficial than the standard modality.