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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for acute care psychiatric hospital services. Findings:  The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. Per the provided documentation, the patient remained symptomatic on the day before the date of service in question. The hospital staff observed the patient attempting to strangle herself after negative interactions with her peers. The patient reported ongoing suicidal ideation and anxiety. She was documented as having extreme despondency and anhedonia. Her mood was documented as anxious, depressed and suicidal ideation was noted. The patient remained on 15 minute safety checks throughout her admission. The American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for youth. The CASII utilizes dimensions that are relevant to the youths clinical status when determining appropriate level of service intensity.  Based on the patients history and clinical status as outlined above, the patient met CASII service intensity criteria for secure 24 hour service with psychiatric management. The patients clinical status, in addition to current medical literature, support the continued inpatient stay provided on the date of service in question. Therefore, acute care psychiatric hospital services provided on the date of service in question 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 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: Experimental/Investigational
Decision: Overturned

A 34-year-old female enrollee has requested total ankle arthroplasty for treatment of her post-traumatic right ankle arthrosis.   Findings:  Two physician reviewers found that the American Orthopaedic Foot and Ankle Society has published a position statement regarding total ankle arthroplasty, which indicates the procedure is a viable option for the treatment of ankle arthrosis. The procedure has been shown to provide pain relief and restore motion in a severely arthritic joint. The patients treatment options were limited and it is not likely she would have experienced better results from other procedures.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services provided for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the residential treatment center services provided were not medically necessary for treatment of the patients medical condition. The standard of care is to treat patients in the least restrictive environment possible. The patient was 96% of her ideal body weight (IBW) and 99% of her IBW later. The patient was medically stable. The patient did not have any suicidal or homicidal ideation. The patient did not have any psychosis, hallucinations, or paranoia. The patient continued to have anxiety around food and cravings for methamphetamine. The patient was motivated for treatment. Given that the patient was not medically compromised, there is data supporting that residential treatment center does not provide advantages over outpatient management. As such, the patient could have been treated in a less restrictive setting. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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 48-year-old female enrollee has requested for the medication Fentora for treatment of her intractable headaches.  Findings:  The physician reviewer found that opioids are controversial for headaches and much of the medical literature does not support the use of opioids for treatment of chronic daily headaches. The evidence is particularly lacking for use of short-acting opioids such as Fentora. In fact, the manufacturers prescribing information indicates that Fentora is used to treat breakthrough pain in adult patients with cancer and must not be used for short-term pain from injuries, surgery, and headaches.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ NuSpin for treatment of his short stature. Findings:  The physician reviewer found that the records provided for review do not support the medical necessity of the requested Nutropin AQ NuSpin for treatment of this patients short stature. Specifically, there are no growth curve and no statement as to the patients genetic target. This is important because the bone age determination suggests the adult predicted height is around 66 to 67 inches and the bone age is not delayed. In patients with GH deficiency, the bone age is characteristically quite delayed. That is a prediction based on a bone age of 13 years at a chronologic age of 14 years 2 months. In addition, the results of the growth hormone stimulation test done in March 2015 demonstrated an abundant growth hormone response, with the peak to 31.0 ng/mL, which might be interpretable as indicative of resistance to growth hormone such as occurs in Laron dwarfism or IGF-1 receptor defects. If this is the case, and is confirmed with a low IGF-I and IGF-BP3, then therapy with Increlex would be more appropriate. However, if he has true resistance to growth hormone, it would have been expected that he would have presented sooner with far more significant short stature, and lower IGF-1 and he would not have any response to exogenous growth hormone therapy. On balance, the growth and stimulation test with the response up to 31.0 ng/mL represents a variation of the normal range and is not indicative of growth deficiency or growth hormone resistance. 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: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested for laser therapy for treatment of her medical condition.  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  This patient has had sciatic neuropathy as a complication of hip surgery.  The medical records indicate severe axonal injury, with partial recovery over time. Axonal injuries recover slowly, and patients may take years to reach maximal recovery.  The medical literature does not show significant benefit from laser treatments in humans with sciatic nerve damage, but animal studies show potential benefit.  Human studies of diabetic neuropathy and ulnar neuropathy also show potential for benefit.  Given the lack of other effective treatments, the requested laser therapy is medically indicated 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 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

A 39-year-old female enrollee requested authorization and coverage of gastric bypass surgery for the treatment of morbid obesity.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested surgery is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: Case Summary: An enrollee with a diagnosis of an enlargement of the right labia minora that is causing functional impairment. She complains of pain with activity and pain with wearing clothes. Examination documents asymmetric significant labia hypertrophy, supported by both her primary care physician and requesting surgeon. This has been a chronic problem. The health plan states that this is considered cosmetic surgery.MD Analysis: Based on the reviewed medical documentation, there is sufficient evidence that this is a functional concern for this patient and that surgical correction can likely be successful. Thus, this is not a cosmetic procedure for this patient. Cosmetic surgery improves on relatively normal structures. Reconstructive surgery addresses functional concerns and/or on relatively abnormal structures. As the planned procedure is to address the patient's functional deficit of pain, it is reconstructive surgery and medically necessary. 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 plastic 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested hospital services on an emergent basis. Findings:  The physician reviewer found that The services at issue were not necessary for treatment of an emergency medical condition. In this case, the patient presented to the emergency department. At that time, her pain had been present of over one week. Her pain was rated as moderate. The patient denied any systemic or neurologic symptoms. Her ear drainage had resolved but the patient had residual erythema of her tympanic membrane. She was prescribed oral antibiotics. The patient presented two weeks later to the emergency department, with reports of persistent ear pain. Her pain had been relieved with over-the-counter pain medication. The patient denied any systemic or neurologic symptoms. Given that the patients symptoms were not acute or sudden, the services at issue were not necessary for treatment of an emergency medical condition. Final Result: The reviewers determined that the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in emergency 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:  The enrollee is requesting authorization and coverage for a bilateral blepharoplasty procedure. The enrollee has experienced gradual drooping eyelids over the last year. She also has cataracts; left greater than right. An eye test showed ptosis. The test demonstrated the need for blepharoplasty surgery to lift her eyelids so her vision would no longer be hampered. The enrollee was referred to an ear, nose and throat-otolaryngologist, who confirmed the enrollee needed surgery. The physician recommended a brow lift and an eyelid lift. The enrollee is requesting authorization of bilateral blepharoplasty. An exam showed brow ptosis and plus-two dermatochalasis bilaterally. Automated visual field testing, performed within 24 degrees of fixation, found the superior visual field restricted to about 18 degrees in both eyes (OU) and increasing to at least 24 degrees OU with taping of the eyelids. Color external photos show dermatochalasis with excess upper eyelid resting 2-3 millimeters above the base of the lashes. Some ptosis is induced with marginal reflex distances of less than 2 millimeters OU. Photos are consistent with visual field testing. The main objective finding in the notes is a superior defect bilaterally, which improved with taping of the eyelids; suggesting blepharoplasty would likely be beneficial. Literature notes repair of blepharoptosis and upper eyelid dermatochalasis significantly improves vision and quality of life activities. According to general standards of practice supported in the peer reviewed literature, blepharoplasty procedures and repair of blepharoptosis are considered medically necessary when performed as functional/reconstructive surgery to correct impairment of near or far vision due to dermatochalasis, blepharochalasis, or blepharoptosis and/or symptomatic redundant skin weighing down on upper lashes.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in ophthalmology 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old female enrollee has requested a bilateral breast MRI for evaluation of the enrollees breast nodules. Findings:  Three physician reviewers found that this patient has bilateral, solid, probably benign lesions as determined by mammogram and ultrasound.  MRI is not indicated as a test in order to determine if biopsy is indicated.  If the lesions are suspicious, ultrasound-guided core biopsies are indicated.  Absent tissue sampling, follow-up ultrasound is also appropriate.  In this patients case, the requested bilateral breast MRI is not likely to be superior over all other methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Botox injections in combination with Aimovig. This patients records document a history of migraine headaches. She has failed traditional migraine control treatments. The patient is currently being treated with Aimovig, which is a calcitonin gene-related peptide (CGRP) antagonist, and Botox, an acetylcholine-blocking agent. The current standard of care for the treatment of patients with chronic migraine is to use a multipronged therapeutic regimen involving different mechanisms of action. This is the reason why using Aimovig, a CGRP antagonist with Botox, an acetylcholine-blocking agent, is useful. Botox also reduces the release of inflammatory cytokines. Research by Dominguez and colleagues suggests that Botox might be more efficacious in patients with elevated serum CGRP levels. As such, using an agent that blocks CGRP such as Aimovig in patients who are good responders to Botox has been shown to have a synergistic effect. Given this support, the requested Botox injections in combination with Aimovig are 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  Three physician reviewers found that the breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, the records documented dense breast tissue.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  In sum, digital breast tomosynthesis performed was likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the service at issue was 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. 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: A male enrollee has requested reimbursement for residential treatment for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that On an initial evaluation, the patient reported chronic suicidal ideation. The patient reported other behavioral issues as well as problems with impulse control and substance use. The patient reported relational issues with his family. During the disputed period, he reported some suicidal thoughts.  It does not appear that he was acting on these thoughts during that time. It appears that the residential treatment was effective for the patient in terms of reducing suicidal ideation as well as reducing substance cravings. The current medical evidence supports residential treatment in this clinical setting. All told, residential treatment was medically necessary 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for amniotic membrane graft of the left ocular surface following excision of a pterygium with Mitomycin-C (MMC). Findings:  Three physician reviewers found the amniotic membrane graft of the left ocular surface following excision of a pterygium with MMC is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. When a patients vision is threatened by the presence of pterygium, excision must be considered. Primary excision without further intervention results in a high rate of recurrence. Recurrences are frequently more aggressive than the original lesion. The use of MMC over the defect has resulted in statistically significant reductions in the recurrence rate. A combination of MMC and either conjunctival autograft or amniotic membrane graft has been shown to be more effective than either therapy alone. Alternatively, conjunctival autograft is associated with higher levels of pain due to the extent of surgery. Amniotic membrane graft has been shown to provide anti-inflammatory properties to aid wound healing and reduce scarring. For this reason, amniotic membrane graft has become the standard of care for minimizing recurrence after pterygium excision. Thus, the requested amniotic membrane graft of the left ocular surface following excision of a pterygium with MMC is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the amniotic membrane graft of the left ocular surface following excision of a pterygium with MMC is likely to be more beneficial for treatment of the patient's medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in ophthalmology 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

A 62-year-old male enrollee requested authorization and coverage of treatment with Celebrex and interferon alpha.  The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees metastatic renal cancer.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer 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 two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.