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

The patient is a 34-year-old man who was admitted to inpatient status on 9/13/2003 and discharged on 9/29/2003. The patient was sent to the hospital via ambulance when his treating psychologist became concerned about the patients safety and deteriorating condition. The submitted clinical information indicates the patient was very seriously ill just prior to his admission. This patient has a 12-year history of depression and has been treated with various medications, which he apparently discontinued on his own requesting inpatient evaluation to establish a baseline. The patient reportedly also admitted to auditory hallucinations and paranoid delusions. The attending physician indicated the patient was paranoid regarding taking his medications while hospitalized. On 9/19/03, the patient started on a course of Remeron, Wellbutrin, and Zyprexa with a reported remarkable response. The Health Plan has denied reimbursement for the services at issue indicating that the patient could have been treated at a less intensive level of care.Review of the detailed clinical records indicates that this patient was experiencing a serious major depressive disorder with psychotic features at the time of his hospitalization. Given the patients deteriorating condition, concerns regarding his safety were justified. As such, acute inpatient behavioral health treatment was medically appropriate and indicated at the time. Therefore, I have determined that the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested for a virtual colonoscopy for evaluation of her given her strong family history of colon cancer. Findings:  The physician reviewer found that the American College of Gastroenterology guidelines for colorectal cancer (CRC) screening, as discussed by Dominic and colleagues, generally suggests a colonoscopy every 10 years beginning at age 50. The authors indicate this frequency of preventative testing is appropriate in patients with a single first-degree relative with CRC or advanced adenoma diagnosed before age 60. For patients with two first-degree relatives with CRC or advanced adenoma diagnosed at a young age, the guidelines recommend a repeat colonoscopy every 5 years beginning at age 40 years, or 10 years younger than the youngest relatives age at diagnosis. Considering that this patient has two first-degree relatives with a history of CRC, she should be followed up with a colonoscopy every five years.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old female enrollee has requested outpatient psychotherapy for treatment of her behavioral health condition.  Findings:  The physician reviewer found that the outpatient psychotherapy provided from the date indicated forward was not and is not medically necessary for this patients medical condition. The patient has received more than three years of weekly psychotherapy treatment; the patients notes reflect no measurable improvements, treatment goals or attainable discharge dates. Despite the therapy received to date, the patient remains symptomatic. According to Gelenberg and colleagues, For psychotherapy, treatment should be reassessed if there has not been a meaningful improvement after a few months. Patients should be reassessed every 3-4 months to ensure adequate improvement. Regardless of treatment modality, lack of improvement over time warrants reconsideration of interventions. Continued weekly insight-oriented sessions are not consistent with the standard of care in this setting. All told, the services at issue have not produced any measurable gains or improvement and continued use of this modality at this frequency is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the FoundationOne gene test performed for evaluation of the enrollees moderately differentiated adenocarcinoma.Findings: The physician reviewer has found that FoundationOne testing offers a comprehensive panel of molecular genetic markers on an individuals tumor with the hopes of identifying markers than can help guide therapy decision making. Per the National Comprehensive Cancer Network (NCCN) guidelines, it has not been determined if molecular markers are useful in treatment decisions and prognosis other than KRAS, NRAS, and BRAF mutations. FoundationOne is the subject of an ongoing phase II trial. All told, there is a lack of peer-reviewed medical literature demonstrating that the FoundationOne testing performed was likely to be more beneficial for evaluation of this patients adenocarcinoma than any available standard testing. Final Result: All three physician reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee requested breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Medical studies and peer reviewed literature support the use of tomosynthesis in this clinical setting.  For these reasons, tomosynthesis was likely to be more beneficial than any available standard therapy.   Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in diagnostic radiology 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

The parent of an 18-month-old female enrollee has requested Synagis for the treatment of the enrollee's potential respiratory syncytial virus (RSV). Findings:  The physician reviewer found that after a very detailed examination of the physician progress notes, respiratory therapy notes, and nursing notes, it is clear that this preterm infant received supplemental oxygen for the majority of the time from birth. This meets the generally accepted definition for chronic lung disease. Given that she has chronic lung disease, and that she has required oxygen and medications to treat respiratory problems during RSV season, she qualifies for Synagis based on both American Academy of Pediatrics (AAP) guidelines and Health Plan criteria. It is therefore both medically necessary and appropriate to provide this infant with palivizumab for the duration of the RSV season.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 61-year-old male who is status post CVA with left hemiplegia, shoulder pain and disuse atrophy.  Conventional treatment such as medication and taping of the shoulder joint have not effectively eliminated his symptoms.  The patient has requested reimbursement and prospective authorization for continued use of the neuromuscular stimulator. The Health Plan denied his request based upon a determination that the device is not medically necessary.The safety and efficacy of the neuromuscular stimulator for the management of extremity and joint pain and disuse atrophy following CVA has not been established. No prospective study has been conducted to support its general use. There is no peer-reviewed evidence that the use of a neuromuscular electrical stimulator is likely to result in an improved clinical outcome for this patient. Therefore, I have determined the device at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee requested authorization and coverage of treatment with thalidomide. The Health Plan  denied the request indicating that thalidomide is considered experimental for treatment of the enrollees metastatic melanoma.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three of the physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Urgent Care
Decision: Upheld

A 48-year-old female enrollee has requested psychotherapy services for treatment of an unknown emergency.  Findings:  The physician reviewer found the submitted clinical documentation fails to demonstrate that a prudent layperson would have sought immediate medical attention in this case. There is no evidence from the records provided that this patient suffered from an emergency medical condition such that the absence of immediate medical attention could reasonably be expected to result in: placing her health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of a bodily organ or part. Moreover, a psychiatric emergency medical condition is defined as a disorder that manifests itself by acute symptoms of sufficient severity that it renders the patient as being either of the following: an immediate danger to himself or herself or to others, or immediately unable to provide for, or utilize food, shelter or clothing due to the mental disorder. There is no evidence from the documents provided that the patients condition would result in placing her health in serious jeopardy/serious impairment to bodily functions/serious dysfunction of a bodily organ or part. There is no evidence that the patient was in imminent danger of harming herself or others, or evidence of suicidal ideation or plan. The documentation also did not provide evidence that the patient was unable to provide for her own activities of daily living (ADLs) or that there was grave disability. Given the above, it has not been established that a prudent layperson would have sought immediate medical attention on the dates of service in question.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee has requested for a pneumatic compression unit with hot/cold contrast for treatment of his post right unicondylar knee replacement. Findings:  Three physician reviewers found that a continuous passive motion machine in combination with a pneumatic compression unit with hot/cold contrast was prescribed for postoperative use. To date, there is no randomized, controlled data supporting the benefit of this equipment over more conventional postoperative treatment modalities. As such, the unit cannot be recommended as either reasonable or medically indicated in this setting.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Two physician reviewers found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Final Result: Two physician reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: All three physician reviewers are 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: Upheld

Findings:  The physician reviewer found that The patient has requested authorization and coverage for acute rehabilitation facility services. The patient has a history of thoracic level myelopathy due to cord compression by metastatic disease. The patient underwent decompressive and stabilizing spinal surgery. The patient has experienced residual paraparesis, neurogenic bladder, and neurogenic bowel. The patient has received rehabilitation services at a skilled nursing facility. The records document that the patient made initial gains, but has largely functionally plateaued. The patient has required maximum assistance to stand and ambulate short distances with a walker. The patient's lower limb motor recovery has been limited. The primary goals of rehabilitation in this clinical setting are maximizing function given the impairments (Nas, et al.; Chay and Kirshblum). There is a lack of indication in the available documentation that the patient has the residual strength to participate and benefit from inpatient rehabilitation services. Given the available documentation, the patients primary rehabilitation goals should include maximizing function, as well as mobility and transfers at a wheelchair level, and self-management of neurogenic bladder and bowel. The patients current issues do not require the services of an acute rehabilitation facility. For these reasons, the requested acute rehabilitation facility services are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a gene test for known or suspected prostate cancer. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees suspected prostate cancer. The gene test for known or suspected prostate cancer was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. PCA3 is an acceptable test in staging for prostate cancer. However, it is not an accepted screening test for prostate cancer. In this case, the patient had a normal PSA. The free PSA of 36% does not suggest a risk for cancer that would support the testing at issue. The PCA3 has the most value as an alternative to a second biopsy when the first was negative and has value to determine the volume, grade and invasion of the cancer.  As such, the PCA3 was not of clinical value in this case. Accordingly, gene test for known or suspected prostate cancer was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three reviewers are board certified in urology 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

The patient is a 39-year-old female who has undergone two courses of Pegasys and Copegus for treatment of hepatitis C. Following the initial course of therapy the patient relapsed. Twelve weeks after the start of the second course of therapy it was determined the patient was non responsive. The patients provider has recommended the patient initiate treatment with Infergen and Copegus. The Health Plan has denied authorization for the proposed therapy on the basis it is not medically necessary.The use of Infergen and Copegus in this clinical setting is medically appropriate and indicated. Infergen has been approved by the Food and Drug Administration for the treatment of patients who are non responsive to traditional hepatitis C therapy. Based on the information provided, the patient is an appropriate candidate for the requested therapy. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 39 hours per week of 1:1 applied behavior analysis (ABA) for six months and eight hours per month of clinical team meetings for six months. The submitted documentation supports the medical necessity of the requested services in this patients case. ABA is the most evidence-based treatment for autism, for both children and adults. Further, the Behavior Analyst Certification Board highlights that treatment intensity and duration is dependent on the patients severity of symptoms and number of goals identified with an emphasis on closing the deficits displayed by the patient and same-aged peers. This patients Vineland scores are two or more standard deviations below the average scores of her same-aged peers. This indicates that the patient is performing significantly below her current age equivalent. The patients provider has outlined 38 goals across a variety of domains, including behavior reduction, safety, communication and daily living. Given the request for 39 hours of 1:1 ABA per week, this equates to working on each goal for approximately one hour each week. Although the patient has displayed a reduction in problem behavior, she is still engaging in a significant level of tantrum behavior. It is important that this behavior continue to be decreased to further close the gap between her performance and the performance of her same-aged peers. Therefore, 39 hours per week of 1:1 ABA for six months and eight hours per month of clinical team meetings for six months are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is a licensed B.C.B.A, board certified in psychology, 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 46-year-old female enrollee has requested continued use of Percocet for the treatment of her multiple sclerosis. Findings:  The physician reviewer found that oral opioids can be effective in treating the pain that frequently accompanies multiple sclerosis. A study by Svendsen demonstrates that MS patients have a high prevalence of pain, and that pain was likely to be described as constant and a significant interference in the daily life of patients with MS. In the study by Rowbathan, MS patients with central neuropathic pain responded better with high dose opioid treatment than with lower dose treatment. This patient has muscle spasms from her MS as well, which also respond in part to opioid treatment. The patient has used both long acting pain medication (MS Contin) as well as short acting medications for breakthrough pain (Vicodin and Percocet). Abrupt discontinuance from long-term opioids can have untoward consequences, including increased pain and precipitation of withdrawal symptoms. It should not be undertaken without close MD supervision. Therefore, there should be a conditional overturn of the Health Plans denial. The patient should continue with her current Percocet dosing until the patient is seen in consultation by a Pain Specialist, who can make recommendations regarding the specific opioid medications and dosing to be used.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 58-year-old female who is 53, weights 254 pounds, and has a body mass index (BMI) of 45. She also has significant comorbid conditions. It is not known if the patient has received psychological clearance for weight loss surgery, but her provider indicates she is psychologically ready for surgery. The patient otherwise meets the NIH guidelines for weight loss surgery. The Health Plan has denied coverage for laparoscopic adjustable gastric banding (Lap Band) based upon their determination that it is not medically necessary for treatment of the patients medical condition.The long-term success of the Lap Band when measured in terms of maintaining excess body weight loss (EBWL) is inferior to the gastric bypass or duodenal switch operations. The limited result of the procedure does not come with limited risk. The Lap Band website reports that in a three-year follow up study of 299 patients with the Lap Band, 88% had post operative complications ranging from nausea and vomiting and reflux to stomach-band outlet blockage.  In this study one-fourth of the patients had their Lap Bands removed.Based upon the information set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.