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

The parent of a 15-year-old female enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that residential treatment center services provided from the specified date forward were not and are not medically necessary for continued treatment of the patients medical condition. The progress notes indicate that the patients mood is stable and any possible psychosis she may have suffered at the time of admission has resolved. She was documented to be social with peers and has been able to go on outings without noted difficulty. A majority of her treatment goals are behavioral in nature and can be worked on and accomplished safely and effectively in a less restrictive setting. Her treatment goals are mostly related to routine activities of daily living that she struggles with due to ritualistic impulses and contamination fears.  She is receiving exposure therapy along with CBT.  Both of these treatments are evidence based, effective treatments for OCD and other anxiety disorders.  The therapy notes indicate that she is involved in exposure therapy in a group setting. This therapy could also occur in a less restrictive setting. Her individual therapy could also occur in a less restrictive setting, such as a partial hospital program. There is little evidence base to support that residential treatment center treatment is superior to less restrictive forms of treatment (McCurdy and McIntyre). Moreover, there is no indication that the patient has any severe, unstable psychiatric symptoms that necessitate a 24-hour placement. Considering the patients status as of the specified date, continued residential treatment center services were no longer medically necessary and transition to a less restrictive setting would have been appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old female enrollee has requested a cooling vest for treatment of her diagnosis with multiple sclerosis. Findings:  Three physician reviewers found that in this patients case, the requested equipment is not likely to be more effective than other treatment options.  The submitted records do not adequately document the patients reported condition, including treatment alternatives that have failed or are contraindicated.  The records do not mention any heat sensitivity issues, and elevated temperatures have not been documented.  No significant clinical benefit would be reasonably expected with the requested device.  Thus, the requested cooling vest is not likely to be of greater efficacy than other treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a pressure reducing mattress for treatment of his ankle fracture. Findings:  The physician reviewer found that a review of the literature and this patients medical documentation does not reveal that the patient meets the medical requirements for a pressure reducing mattress. There is no documentation that this patient is completely immobile or unable to make position or weight shift changes. Further, there is no evidence of a current pressure ulcer or altered sensation, impaired nutritional status, or incontinence.  Final Result: The reviewer determined that the requested device 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Vascepa for treatment of her hypertension, hyperlipidemia and hypertriglyceridemia. Findings:  The physician reviewer found that per the submitted records, this patient is at risk for coronary heart disease. The patients laboratory report includes very high triglycerides, and increased liver enzyme tests while on low intensity statin medication.  In this circumstance where a patient presents with very high triglycerides, in spite of maximum tolerated statin medication, additional treatment to reduce triglyceride levels is clinically reasonable and appropriate. Standard accepted practice in the medical community supports treatment options of medications which are directed at reducing triglycerides. These medications include fibrates, nicotinic acid, and fish oil. However, both fibrates and nicotinic acid are contraindicated with preexisting liver enzyme elevation in this patient. Likewise, higher dose statin medications are relatively contraindicated for the same reason. Therefore, the preferred medication for treatment of this patient's medical condition is a fish oil preparation, such as Vascepa with close monitoring of liver function enzyme levels. In sum, the requested medication 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 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 67-year-old male enrollee requested authorization and coverage of laparoscopic radical prostatectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for 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: Medical Necessity
Decision: Overturned

The patients parent has requested reimbursement for psychiatric residential treatment center (RTC) services.  The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Applying the CALOCUS framework, this patient met the criteria for RTC services. The patient was at significant risk of harm due to prior suicidality and self-harm, as well as multiple prior attempts and hospitalizations. Despite multiple prior psychiatric hospitalizations, she has only demonstrated recent gains in the RTC setting. The patient has been constructive with treatment, considering her positive engagement in treatment, and high extrinsic motivation, but lower intrinsic motivation, per the records. This gives the patient a composite score of 18. However, given the patients score for comorbidity, the appropriate level of care is Level Five, Medically Monitored Residence-Based Services, similar to the services provided at the RTC facility. Given this patients history of suicidality and self-harm, combined with continued body image concerns, the RTC 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 subspecialty 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: Experimental/Investigational
Decision: Upheld

A 26-year-old male enrollee has requested ProDisc-C total disc arthroplasty for treatment of his neck pain and left arm pain and numbness. Findings:  Three physician reviewers found that the medical records note left cervical radiculopathy from left C5-6 disc extrusion. Significant spinal stenosis was noted at this level. There is a lack of long-term level one or level two evidence in the peer-reviewed literature concluding that cervical arthroplasty is more beneficial than fusion in terms of safety and effectiveness.  Randomized controlled trials to date, while demonstrating favorable findings in support of cervical arthroplasty, are short-term to intermediate-term in follow-up length. The most touted advantage of arthroplasty over fusion, reducing adjacent-level degeneration, has not been demonstrated in randomized controlled trials to date.  At this time, reduction of adjacent-level degeneration remains only a theoretical advantage, not a clinical reality. Additionally, long-term, adverse effects of arthroplasty materials, such as metals and polymers, are not known at this time.  All told, the superior efficacy of the requested ProDisc-C total disc arthroplasty has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

The enrollee requested reimbursement for endoscopic sinuplasty with balloon dilation. The enrollees otolaryngologist has recommended balloon or open surgery as the enrollees condition has not improved with aggressive medical therapy; both systemic and topical. The enrollee still complains of right frontal headaches. The enrollees otolaryngologist indicates a regulatory body has cleared the balloon catheter procedure for use as a surgical tool for opening the sinus ostia. This enrollees symptoms have not been relieved with comprehensive medical therapy. Her computed tomography scan shows opacification and obstruction of the right side sinus recesses frontal/sphenoid. Balloon sinuplasty has been shown to have long-term effects comparable to traditional surgery, with less recovery time, and the procedure allows for maintenance of the natural drainage pathways. Literature indicates endoscopic sinus surgery for those with chronic rhinosinusitis who have failed medical therapy has been performed in the office setting, under local anesthesia, for 14 years. Literature notes balloon catheter dilation is associated with low risks of complications and revisions. The procedure is well tolerated and effectively treats both chronic rhinosinusitis and recurrent acute rhinosinusitis. This enrollee underwent surgical sinusotomies. However, her symptoms persisted and she still complained of congestion and frontal headache. The clinical decision for advocating the use of balloon sinuplasty appears to be based upon this diagnostic. This would constitute objective evidence and indications for a balloon sinuplasty. Peer-reviewed literature demonstrates balloon sinuplasty would be more beneficial than standard treatments for this enrollee. It is a less invasive procedure than a sinus operation.Final Result: Three of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in otolaryngology 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: Overturned

A 33-year-old female, with a prior history of major depression, has requested authorization for acute inpatient psychiatric services.Reviewers Findings:The reviewing physician found that given the patients prior history of major depression, she was clearly at increased risk of relapse following the birth of her son. The dosages of her psychotropic medications prior to admission were quite high, but provided no benefit. Her inpatient course was appropriately managed, without an undue length of stay, and with clearly documented improvement.
Appeal type: Experimental/Investigational
Decision: Overturned

A 64-year-old female enrollee requested cancer gene testing (CPT codes 81211 BRCA 1 and 2, 81210 BRAF gene, 81213 BRCA 1 and 2, 81235 EGFR gene, 81275 KRAS gene, and 81292 MLH1 gene) for medical evaluation of the enrollee, who has a family history of cancer.  Findings:  Two physician reviewers found that screening for BRCA mutations is indicated for individuals whose personal or family history predicts a high likelihood of finding one of these mutations. Identifying individuals who carry these mutations has clinical importance in that it mandates the adoption of special measures aimed at risk reduction.  Well-established guidelines identify those individuals in whom genetic screening is warranted.  Per the current guidelines, an individual with a first-degree or second-degree relative diagnosed with breast cancer at age 50 or younger is considered high risk and is eligible for testing.  Since this patients grandmother was diagnosed at age 45, testing is indicated.  Cancer-relevant mutations in the genes KRAS, BRAF, and EGFR are not germline, meaning that testing for them is not appropriate in individuals with no history of cancer.  The MLH1 gene is relevant in families suspected of a predisposition to the Lynch syndrome, in which affected families are at increased risk of developing colon cancer.  Given the patients history of only a brother with colon cancer at age 67, testing for the Lynch syndrome is not warranted.  All told, a portion of the services at issue (BRCA 1 and BRCA 2 testing) was likely to have been more effective than other methods of evaluation.  However, the current medical evidence has not demonstrated the superior efficacy of the remainder of the gene testing.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 62-year-old female who is 49. She was formerly morbidly obese. She underwent a gastric bypass procedure with a resultant weight loss that has caused excess abdominal wall skin and fatty tissue. The patients history is also significant for neurological symptoms and anticoagulation. The patient has requested authorization and coverage for panniculectomy and abdominoplasty. The Health Plan has denied authorization and coverage for the requested surgery on the basis it is not medically necessary for treatment of the patients medical condition.Massive weight loss following gastric bypass results in significant redundant tissue. Most commonly, the dependent skin develops symptoms related to moisture, friction and intertrigo. In the case of this patient, she has a large hanging pannus over the mons pubis. The submitted photographs suggest intertriginous skin changes beneath the pannus. As such, the patient meets ASPS criteria for the requested surgery. Therefore, I have determined the requested surgery is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services including physical therapy and occupational therapy services provided for treatment of the enrollees transient ischemic attack (TIA), epilepsy, and pressure ulcers. Findings:  The physician reviewer found that based on the medical records provided for review, the SNF services including physical therapy and occupational therapy services provided were not and are not medically necessary for treatment of this patients medical condition. Patients require SNF services or skilled rehabilitation services when they are needed on a daily basis and the daily skilled services can be provided only on an inpatient basis in a SNF. The documentation does not reveal that this patient requires SNF services. There is a lack of evidence that the patient requires such SNF services as intravenous or enteral feeding (enteral feeding that comprises at least 26% of daily calorie requirements and provides at least 501 milliliters of fluid per day), tracheotomy aspiration, suprapubic catheter care, treatment of a stage 3 or greater decubitus ulcer, institution of a bowel/bladder training program, colostomy care or other SNF need. While the patient may benefit from continued therapy, the documentation does not support that the patient requires these services on a daily basis or only as an inpatient in a SNF. The patient has made slow progress per therapy documentation and has had left-sided weakness prior to this SNF from his stroke. Therefore, the patient is not expected to make measurable gains within a reasonable and predictable period of time. The patient does not require skilled therapy on a daily basis to prevent deterioration with mobility and/or activities of daily living, he does not have medical needs that require skilled nursing services to prevent a deterioration in his condition, and the patient does not require skilled therapy to establish a safe and effective maintenance program. Without clear skilled nursing needs the patient does not require SNF services to establish a safe and effective maintenance program. For these reasons, this patient does not require the necessary services on an inpatient basis at a SNF level and care and his current needs can be met at a lower level of care. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for OxyContin four times daily or OxyContin two times daily for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the clinical notes document chronic low back pain and pelvic pain.  Per the medical evidence, OxyContin should not be dosed on a four times daily regimen. OxyContin is appropriately dosed twice daily, as this is an extended release, high-dose opioid regimen.  In this patients case, the clinical notes support the medical necessity of OxyContin two times daily for the treatment of her pain.  However, there is a lack of support for OxyContin four times daily. Final Result: The reviewer determined that that a portion of the requested medication quantity is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee has requested for Avastin and Ixempra combination chemotherapy for treatment of her metastatic breast cancer.   Findings:  Three physician reviewers found that Ixempra (ixabepilone) is a new drug that has recently been approved for use in metastatic breast cancer in patients whose cancer appears to be refractory to taxanes, anthracyclines, and Xeloda. This patient falls into that category. Avastin (bevacizumab) has been approved for use in first line treatment for metastatic breast cancer, when used with taxol. There is no real data as to whether it is of any use when given later in the course of the disease, nor whether it should be used after the disease has progressed while on the drug. In the absence of such data, the continued use of Avastin in this situation must be considered investigational, and of no proven clinical benefit.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested Nutropin for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the current medical evidence does not support the medical necessity of the requested medication.  Growth hormone treatment is not indicated for growth failure in association with chronic illness and will have limited efficacy in the setting of concomitant steroid administration, even at doses of steroids that are relatively low.  This patients insulin-like growth factor 1 (IGF-1) level is appropriate for a pre-pubertal/early pubertal female and is not indicative of bona fide growth hormone deficiency.  The growth velocity would be expected to pick up as puberty progresses, as long as the underlying chronic disease is well-controlled.  All told, the requested Nutropin is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology 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 54-year-old male enrollee requested Norco (hydrocodone/acetaminophen) for medical treatment of his migraine headaches.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patient has chronic migraine headaches with limited prior preventive trials and medication-overuse headache (MOH). Treatment of MOH consists of combining prophylaxis, 100% wean of overused acute medications, and provision of new acute medications, strictly limiting use to 2 or fewer days per week (Tepper). As opiates have poor evidence for management of migraine, with evidence of potential harm, they should not be continued except as rare rescue therapy. Therefore, a prescription for opiates (Norco) is not clinically indicated. All told, the medical necessity of the requested medication has not been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old female enrollee has requested for a bone growth stimulator (electric and ultrasonic) for treatment of her condition.   Findings:  Three physician reviewers found that this patient does not have a diagnosis of a non-union long-bone fracture, and therefore, there is no indication for a bone-growth stimulator.  The use of a bone-growth stimulator in this setting has not been shown to have clinical value. In the absence of scientific data to support its use in this setting, a bone-growth stimulator is not likely to result in superior benefit.