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

The parent of a 15-year-old female has requested past and future coverage for residential treatment for treatment of her depression and polysubstance abuse.  Findings:  The physician reviewer found that the patient does not meet standard residential treatment admission criteria because she does not pose a threat to herself or others. Although she stated she has had fantasies about killing her mother, she has stated she would not act upon these thoughts. Furthermore, she was living with her father at the time of admission to treatment and had a good relationship with him. A review of the progress notes indicates that the patient worked hard in treatment, but was never considered unsafe. There were minor changes made to her medication regimen, but no changes that would require monitoring as provided in a 24-hour RTC level of care. She was listed as having a single episode of running away, but told her therapist that this was a misunderstanding. She has no additional medical issues that would complicate her treatment. Overall, the patients psychiatric problems require little additional medication management and could be safely and adequately managed in a less restrictive treatment environment.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old female has requested a pulmonologist referral and pulse oximetry machine for treatment of shortness of breath and chest pain.  Findings:  The physician reviewer found that there are no findings to support the need for the requested pulmonology referral. It appears that at this point, pulmonary function testing would be appropriate. If the results show a need for further evaluation, a referral to a pulmonary specialist would be indicated. However, based upon the information presented at this time, a consultation with a pulmonology referral is not medically necessary. Furthermore, there is no clinical indication for a pulse oximeter in this case. The patients sleep study showed that her oxygen saturation is normal. There is no clinical utility to having the patient monitor her oxygen saturation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Supartz injections. Findings:  The physician reviewer found that the medical literature and submitted documentation support the medical necessity of the services at issue. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. As noted by a medical study, there is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long lasting as compared with intraarticular corticosteroids. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around 2 years. The authors performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Their review found that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for up to 26 weeks. Intra-articular hyaluronic acid has a good safety profile, and its use should be considered in patients with knee osteoarthritis. In this case, the submitted medical records document subjective, objective, and radiographic imaging findings consistent with osteoarthritis of the knee. The patient has failed conservative treatment, including cortisone injections. Under these circumstances, the Supartz injections provided to the patient were medically necessary for the treatment of the patients medical condition.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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an eight-year-old male enrollee has requested  physical therapy for treatment of the enrollees knee pain.  Findings:  The physician reviewer found that while physical therapy may well be indicated for a knee injury after trial and failure of standard therapies, this patients records do not indicate treatment with conventional modalities of rest and non-steroidal anti-inflammatory drugs (NSAIDs). The treating physicians notes do not document recommendations for these proven, first-line treatments. Without documentation of a trial and failure, or contraindication to NSAIDs, the requested physical therapy has not been established to be medically necessary for management of this patients knee pain.
Appeal type: Experimental/Investigational
Decision: Overturned

A 69-year-old male enrollee has requested Oncotype DX testing for evaluation of his colon cancer.  Findings:  Two physician reviewers found the use of adjuvant chemotherapy in patients with resected stage II colon cancer has been a subject of controversy within the oncology community.  Clinical trials have provided varied conclusions as to the benefit of treatment in these patients, and consensus guidelines recommend that a decision to treat be based on the presence of certain high-risk features which predict a higher probability that these patients will experience recurrence.  The Oncotype DX assay has been shown to predict with some accuracy the risk of recurrence in patients with resected stage II colon cancer.  In this patients case, the requested Oncotype DX testing is likely to be superior over other methods of evaluation.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for percutaneous tibial nerve stimulation (PTNS) provided for treatment of the enrollees interstitial cystitis. Findings:  2/3 of the physician reviewers found that the procedure for PTNS consists of the insertion of a needle above the medial malleolus into the posterior tibial nerve followed by the application of low-voltage (10 mA, 1-10 Hz frequency) electrical stimulation that produces sensory and motor responses. Noninvasive PTNS has also been delivered with surface electrodes. The recommended course of treatment is an initial series of 12 weekly office-based treatments followed by an individualized maintenance treatment schedule. There is evidence in the peer-reviewed literature from randomized trials and prospective observational trials supporting the clinical utility and impact on patient management of PTNS in patients with urinary urgency and frequency as in this case. However, most trials have a small number of patients with short-term follow-up. Moreover, the role of PTNS in patients with interstitial cystitis is largely unknown. Most studies evaluating efficacy of PTNS in interstitial cystitis are small retrospective studies with conflicting results. Overall, the current scientific evidence does not support routine use of PTNS in patients with interstitial cystitis. Thus, the PTNS provided was not and is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the services at issue were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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.
Appeal type: Medical Necessity
Decision: Upheld

A thirty-five year-old female with breast hypertrophy is requesting authorization for a bilateral breast reduction.Reviewers Findings:  The reviewing physician found that this patient has symptomatic macromastia, and that the complaints are functional rather than cosmetic, the proposed reduction may be too small to relieve the symptoms.  The reviewing physician fund that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for brand name Prozac 20 mg and Femring 3.5 mg. Findings:  The physician reviewer found that this patients specific menopausal symptoms and the improvement with Femring are not documented. The records do not include discussion of systemic hormone treatment risks and benefits, nor do the records indicate why the patient is not a candidate for other types of hormone replacement, including those on the Health Plans formulary. Per the North American Menopause Society guidelines, use of low-dose intravaginal estrogen does not require additional progestin. The authors also indicate that Estring is considered low-dose intravaginal estrogen therapy, but Femring is not considered in the same category as it delivers systemic levels of estrogen. Accordingly, the requested Femring 3.5 mg is not supported as medically necessary for treatment of this patients medical condition. In addition, the patient has reportedly been stable on brand name Prozac for over 10 years. Although the records indicate that the patient takes Prozac to alleviate symptoms of multiple sclerosis, there is no documentation of the patients specific symptoms of multiple sclerosis that are improved while on the Prozac. The record is also not clear on how the patient is to take the Prozac as the dosage and frequency are inconsistent in the records. All told, the requested Prozac 20 mg is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medications 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 family practice 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for biofeedback and hypnotherapy for treatment of the enrollees post-traumatic stress disorder (PTSD), severe depression, and anxiety. Findings:  2/3 of the physician reviewers found that colleagues reviewed 70 studies including 4,761 patients and reported that trauma-focused cognitive behavioral therapy was superior to other therapies including hypnotherapy and biofeedback. In addition, the American Psychiatric Association (APA) reported that there is a paucity of study on hypnosis have been conducted that would establish evidence-based evidence of their efficacy as an early or preventive intervention for acute stress disorder or PTSD. Based on these accepted guidelines, trauma-focused cognitive behavioral therapy remains superior to hypnosis or biofeedback. Trauma-focused cognitive behavioral therapy is considered standard of care and evidenced based treatment for the treatment of PTSD. Therefore, the requested biofeedback and hypnotherapy are not likely to be more beneficial for treatment of the patients medical condition than standard evidence-based therapy. Final Result: 2/3 of the reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old female enrollee has requested for a duodenal switch for treatment of her morbid obesity.  Findings:  The physician reviewer found that there is high incidence of weight regain and inadequate weight loss with gastric bypass. Nutritional deficiencies common after gastric bypass are iron deficiency anemia, protein malnutrition, and poor eating habit secondary to the stricture at the gastro-jejunostomy anastomosis.
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 the current medical evidence supports the services at issue in this clinical setting.  Per the medical literature, this technique may result in a decrease in callbacks and increase in detection of small cancers.  There is sufficient support for breast tomosynthesis in this patients case.  In sum, the addition of breast tomosynthesis to the two-dimensional protocol was likely of more benefit to the patient than had the exam 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 physician 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 coverage for wireless capsule endoscopy. Findings:  Two physician reviewers found that , the patient has iron deficiency anemia and is symptomatic with fatigue. The American Gastroenterological Association guidelines recommend video capsule endoscopy to investigate patients with iron deficiency anemia and/or evidence of gastrointestinal bleeding when EGD and colonoscopy do not provide an explanation. The American Society for Gastrointestinal Endoscopy (ASGE) guidelines also recommend capsule endoscopy for investigation of gastrointestinal bleeding or iron deficiency anemia. Compared with the enteroscopy for detecting a small intestinal bleeding source, capsule endoscopy has sensitivity of 95%. In comparison with computed tomography angiography (CTA) and standard angiography, capsule endoscopy detects more bleeding source lesions. Based on the records submitted for review, the source for anemia is not conclusive, thus the clinical literature supports the use of wireless capsule endoscopy. Final Result: Two reviewers determined that the requested service is 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 physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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

A 57-year-old female requested authorization and coverage of a home portable oxygen machine for treatment of chronic obstructive pulmonary disease.  The health plan denied the enrollees request indicating the requested equipment 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 equipment is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested Erbitux therapy for the treatment of her lung cancer. Findings:  Three physician reviewers found that Erbitux is FDA approved for colorectal and head and neck cancer. It is not compendium listed or included in the recommended treatment options under the NCCN consensus panel recommendations for non-small cell lung cancer. There are no randomized, controlled trials showing that the addition of Erbitux to Alimta will lead to an improvement in outcome.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested an inpatient hospital stay for treatment of her medical condition.  Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for inpatient hospital stay has not been established. According to Lippmann and Lukacz, same-day discharge from the hospital after laparoscopic hysterectomy is a safe option for women without perioperative complications or comorbidities that require inpatient observation and care. The patient was admitted for an elective laparoscopic hysterectomy with salpingo-oophorectomy. There were no acute signs or symptoms at the time of admission and no uncontrolled comorbid conditions. The procedure note documented that the patient tolerated the procedure well. There was minimal bleeding. The Post-Anesthesia Care Unit (PACU) course was uneventful and the patient was admitted to the hospital with orders for routine monitoring of vital signs, post-operative laboratory studies and Foley insertion for urinary retention. There was no documentation from the physician as to why the patient was admitted as an inpatient, as opposed to being discharged or remaining on observation status following recovery. The patient remained stable with minimal bleeding, and no fever. She could have been treated at a lower level of care. For the reasons provided, the services at issue were not medically necessary.  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 internal 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: Overturned

A 47-year-old female enrollee has requested coverage for a past MRI of the breast including computer-aided detection (CAD)for evaluation of her stage IV lobular breast cancer.  Findings:  Three physician reviewers found that the patient has a family history positive for breast cancer. The patient was noted to have very dense breast tissue on mammography. She was found to have invasive lobular carcinoma in the left breast metastatic to the left axilla. She underwent a PET/CT scan and an MRI. The MRI revealed a suspicious area in the superior aspect of the right breast, which could not be biopsied due to difficulty in positioning the patient following her left mastectomy.  A follow-up MRI of the breasts utilizing computer-aided detection (CAD) was performed, which revealed two foci of abnormal enhancement in the right breast.Review of the submitted clinical documentation demonstrates that this patient has very dense breast tissue as reported on mammography. The proven diagnosis of invasive lobular carcinoma of the breast is a disease with at least 25% bilaterality. The very dense breast tissue on mammography virtually excludes that technique for adequate screening of such a patient. MRI is the most sensitive means of screening for breast cancer and in this patient who already had an abnormal MRI examination there is no other technique available to provide the necessary information. As such, the MRI with CAD was the best method by which to evaluate this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for residential treatment center for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the RTC services were medically necessary for treatment of the patients medical condition. Per the Child and Adolescent Level of Care Utilization System (CALOCUS), the patient does meet the criteria for residential treatment. The patient was at a significant risk of harm with extreme distress and a history of suicidal behavior. Her functional status was seriously impaired as she consistently had conflictual or disrupted relations with others. In addition, she had significant comorbidity of both substance use disorder and anorexia. She demonstrated poor resiliency and a poor response to treatment and was ambivalent, avoidant and distrustful in her relationships. In this clinical setting the RTC services at issue were medically indicated. For the reasons provided, the RTC services provided were medically necessary for treatment of the patients medical condition. Final Result: The reviewers 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: Physician reviewer number one 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.