Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the PuraPly graft provided.  Findings:  The physician reviewer found that most wounds have biofilm, which can prevent wound healing . The clinical indication for PuraPly is in biofilm reduction and wound stability. However, this patients biofilm could have been addressed with a more standard approach such as topical antibiotics or continued debridement . In addition, offloading was recommended as a key component in wound healing. The records indicate that the patient was not being compliant with his offloading boot. For those reasons, the PuraPly graft provided on the date of dispute was not likely to have been more beneficial as compared to standard approaches for treatment of this patients medical condition. Final Result: The reviewers determined that the service at issue was 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 upheldCredentials/Qualifications: Physician reviewer number one is board certified in family medicine and is actively practicing. Physician reviewer number two is board certified in internal medicine with sub-specialty certification in infectious disease and is actively practicing. Physician reviewer number three is board certified in dermatology and is 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: Upheld

A 44-year-old male enrollee requested authorization and coverage of a full body MRI. The Health Plan denied the request indicating that the requested MRI is not medically necessary for evaluation of the enrollee status post motor vehicle accident.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested MRI is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for autonomic testing (tilt table testing). Findings:  Three physician reviewers found the submitted documentation supports the requested services in this clinical setting. An emotional component, although considered, has been ruled out as the major etiology of the patients dizziness and lightheadedness. A unifying diagnosis is needed, whether its etiology resides in the autonomic, central nervous, or immune-mediated systems. An appropriate next step is to assess the autonomic nervous system with a tilt table test to rule out a primary autonomic system dysfunction. Per the medical evidence, autonomic dysfunction generally starts around the age of 15.  Tilt table test is the initial evaluation in the evaluation of possible autonomic dysfunction. All told, the requested autonomic testing (tilt table testing) is likely to be of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are 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: Physician reviewers 1, 2 and 3 are board certified in neurology with special qualification in child neurology 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 49-year-old female patient with a history of breast cancer. She is undergoing chemotherapy. She has a BMI of 35.4 with multiple comorbidities including hypercholesterimia, GERD, degenerative joint disease, and hypertension. The patient has had documented attempts of failed non-surgical approaches to weight loss and is now requesting authorization for laparoscopic restrictive vertical gastroplasty/gastrectomy. The Health Plan has denied her request. The patient meets NIH criteria for weight loss surgery with a BMI greater than 35 and her documented comorbid conditions. It is clear that weight loss will not only benefit the patients general health, but also the long-term outcome of her breast cancer. This is based on the fact that the hormonal changes that follow weight loss are consistent with reduction of estrogen level, which is stored/converted in peripheral adipose cells. As the patients providers indicate, a purely gastric restrictive procedure is more appropriate in this patient given her history of breast cancer. Therefore, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. Documentation of psychological clearance should be obtained prior to weight loss surgery.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Otezla for treatment of her plaque psoriasis. Findings:  The physician reviewer found that this is a case of plaque psoriasis on 10% of the body to involve the elbows and nails per the medical records. The patients history is also complicated by hyperlipidemia on medication and heart disease. The records indicate that the patient has failed topical medications. Furthermore, the records also indicate that she has hand psoriasis in addition to the nails make injecting anti-TNF agents difficult and painful. The patient has tried the requested medication and has noted improvement.  As such, the request for Otezla is medically necessary. 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 certifications in rheumatology, allergy and immunology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency services. This patient had a tracheostomy and external ventricular drain (EVD) in place at the time of transport. The patient has been diagnosed with lupus with central nervous system complications resulting in altered sensorium. The patient required skilled nursing services during the flight given their need for intensive care services. The patient was in a stable but guarded condition during the days of the flight. Therefore, the flight provided was for the transport of a patient for emergency medical services and the patient received services during the flight including the management ventilator settings during the flight. For these reasons, the services were necessary for treatment of the patients emergency medical condition.Final Result: The reviewer determined that the services at issue necessary for treatment of the patients emergency 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

Nature of Statutory Criteria/Case Summary: The guardian of an enrollee has requested reimbursement for residential treatment center services. To objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted, national standard for determining the appropriate level of care for children and adolescents. In terms of risk of harm, the records support a score of 2. The patient does not have a history of any suicide attempts. Prior to admission, the patient had passive suicidal ideation, with no plan or intent. By 10/26/17, the patient did not have any suicidal ideation. The patient superficially cut herself prior to admission. With regards to functional status, the records support a score of 3. The documentation stated that the patient had interpersonal deficits with her peers which she would like to improve. She is described as mature. In terms of comorbidity, the records support a score of 2. She has no medical problems that would require frequent monitoring. With regards to environmental stress of the recovery environment, the records support a score of 3. The patient had a serious disruption in her family milieu after her adoptive mother passed away. She was living with her guardians who struggle to care for her. In terms of environmental support, the records support a score of 3. The guardians are supportive, but they admit that they are too advanced in years to give the support that the patient requires. However, another family relative is supportive. With regards to resiliency, the records support a score of 3. The records indicate moderate response to treatment.  In terms of acceptance and engagement, the records support a score of 2. The patient had a positive relationship with clinicians and other care providers. She actively participated in treatment planning and cooperated with treatment. Thus, the records support a composite score of 18. Based on these criteria, the patient met criteria for an intensive outpatient program (IOP). Therefore, residential treatment center services provided from 10/26/17 through 11/20/17 were not medically necessary for the treatment of this patient. 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 with expertise in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee has requested laparoscopic adjustable gastric band surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that the patient has a BMI of 35 and multiple obesity related comorbidities that will be ameliorated or eliminated by bariatric surgery. Although her comorbidities have been medically controlled, they are progressing and require increasing numbers and classes of drugs. Her hemoglobin A1C is rising and is now 6.5. The patients lipid profile remains worrisome. She has had excellent therapy from Scripps Clinic which has optimized her health and provided support for non-operative weight control. Despite this, comorbidities have progressed. She fulfills criteria for bariatric surgery. The requested procedure is an appropriate and medically indicated procedure.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for irinotecan and bevacizumab. The National Comprehensive Cancer Network (NCCN) guidelines do not include irinotecan and bevacizumab in their recommendations for the treatment of this patients metastatic cholangiocarcinoma. In addition, the combination of infusional 5-fluorouracil (5-FU) with irinotecan and bevacizumab produced some responses in five of 13 patients. However, this is not the same regimen requested for this patient, as infusional 5-FU is not included. Further, the current data is from small studies with limited follow-up. Given these findings, the requested irinotecan and bevacizumab are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested irinotecan and bevacizumab are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication regimen is 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: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty 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 has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that in this patients case, the medical evidence has demonstrated the superior effectiveness of the services at issue.  Breast tomosynthesis allows radiologists to separate dense glandular tissue from underlying architectural distortion, thereby resulting in a decrease in callbacks and increase in detection of small cancers.  Based on the submitted records, the addition of breast tomosynthesis to screening digital mammogram was likely of greater benefit to the patient than had the mammogram been done with two-dimensional imaging alone. Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for proton beam radiation therapy. Findings:  The physician reviewer found that A significant concern for treatment mediastinal lymphomas is the risk of secondary malignancy, especially in younger patients. Hoppe and colleagues report that compared with three-dimensional conformal radiotherapy (3D-CRT) and intensity-modulated radiotherapy (IMRT), proton therapy reduces the radiation doses to all major cardiac subunits. Timlin and colleagues estimate that proton therapy decreases the average risk of a secondary cancer due to radiation therapy by 40% when compared to IMRT. The International Lymphoma Radiation Oncology Group (ILROG) supports the use of proton therapy for young, female patients in this clinical setting. In this case, given that proton therapy was likely to have been more effective in decreasing long term toxicity, especially secondary malignancy, in this young, female patient, the service at issue was likely to have been more beneficial than any other standard treatments for her condition. Therefore, proton beam radiation therapy was likely to have been more beneficial for treatment of the patient's condition than any available standard therapyFindings:  Two of the three physician reviewers found the proton beam radiation therapy at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to have been more beneficial for treatment of the patients 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 radiation 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: Medical Necessity
Decision: Upheld

The parent of a nine-year-old female has requested approval for past and future in office orthoptic therapy for treatment of her ocular motor dysfunction.   Findings:  The physician reviewer found that the requested vision therapy is not supported as medically necessary for treatment of this patients medical condition. The medical literature contains weak to moderate evidence that office based vision therapy is beneficial for children with convergence insufficiency. One randomized clinical trial demonstrated that a group of patients ages 9 to 17 experienced greater symptomatic improvement after 12 weeks of office based convergence/accommodative therapy with home reinforcement, than with less intensive home based treatments. These results were obtained with a very specific protocol of office and home based therapy. Overall, there is no standardized method of treatment for convergence insufficiency. In this patients case, a 12 to 16 week group of therapy sessions was recommended for treatment of poor accommodation and other non-specific dysfunctions. As noted by American Academy of Pediatrics, American Academy of Ophthalmology, and American Association for Pediatric Ophthalmology and Strabismus, there is inadequate evidence to support the use of vision therapy for treatment of poor accommodation, or symptoms of headache and dizziness (Handler, et al). All told, the vision therapy at issue was not and is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested lumbar spinal fusion for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  A discogram is noted to be positive for concordant pain.  However, there is no evidence of spondylolisthesis, instability on flexion/extension films at the level of the herniation.  The documentation also does not indicate if any iatrogenic instability will be created intraoperatively that would necessitate a fusion.  The medical evidence is insufficient to support lumbar fusion being more effective than nonsurgical treatments in patients with and without prior surgery.  The evidence for lumbar spinal fusion does not conclusively demonstrate short-term or long-term benefits compared with nonsurgical treatment.  The documentation provided does not indicate any neurologic deficit in the left lower extremity corroborating the MRI findings of a herniated disc.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested lumbar spinal fusion is not medically indicated for the 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.  Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast reduction surgery for treatment of her bilateral breast hypertrophy.  Findings:  The physician reviewer found that the submitted documentation supports the requested services in this patients case.  She has well-documented severe symptomatic macromastia. Her symptomatology, examination detail and review of the photographs are supportive of this. She has multiple functional deficits supported by typical signs and symptoms associated with macromastia. She has neck and back pain as well as shoulder grooving from bra straps. She has evidence of severe macromastia on examination detail and review of the photographs. Her pain has failed conservative management with nonsteroidal anti-inflammatory drugs. She would likely benefit significantly from breast reduction surgery. Breast reduction is a well-known procedure that directly addresses functional compromise. Final Result: The reviewers 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 number two 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: Experimental/Investigational
Decision: Overturned

A 60-year-old female enrollee has requested PET/CT imaging for evaluation of ovarian cancer.   Findings:  Three physician reviewers found that the sensitivity and specificity for combined PET/CT is higher than CT alone; 83% versus 70% for sensitivity and 92% versus 83% for specificity. The negative predictive value is also higher for PET/CT combined versus CT alone; 73% and  59% respectively. Studies have shown that PET is more sensitive than CT for suspected recurrent ovarian cancer when there is a rising CA 125. In a study of 56 women, PET/CT resulted in a major change in treatment plan for 58% of the patients. In another recent study it was concluded that, FDG-PET/CT has the greatest utility in settings of suspected ovarian cancer recurrence, particularly in patients with rising CA-125 levels and negative conventional imaging.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for tamsulosin HCL.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has pelvic floor dysfunction. The provider wishes to treat urinary hesitancy with alpha blockers. Multiple alpha blockers are available to treat this condition. These include tamsulosin, alfuzosin, terazosin, doxazosin and silodosin. Current medical literature does not support the superior efficacy of tamsulosin over alfuzosin, the Health Plans preferred alternative. The documentation does not support prior trial and failure of the preferred alternative. Hence, tamsulosin HCL is not medically necessary 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 urology 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.