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

A 54-year-old female has requested approval for past acute medical services provided for treatment of her failure to thrive and acute bladder infection.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient continued to have stable renal function.  The patients potassium level on a date at issue was only mildly elevated at 5.5.  It was not associated with arrhythmia, electrocardiogram changes, or symptoms such as muscle weakness.  No intravenous medications were provided to lower the potassium, and it was normal on subsequent laboratory testing.  Dialysis was not required, and she did not have volume overload, uremia, or severe acidosis.  She remained hemodynamically stable, without fever or new medical issue.  The patient did not have active psychosis on the dates in question, and she was not a danger to herself or others.  No parenteral sedative agents were required.  The patient was stable for discharge to a lower level of care as of the date at issue.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old man who was apparently diagnosed with stage I chronic lymphocytic leukemia (CLL) in March 2000. Based upon the information provided, it does not appear that he received any specific therapy for this condition. The patient also has a chronic pain syndrome, for which he was seen by a rheumatologist. He was started on Celebrex some years ago with symptomatic improvement. In August 2002, the patient was hospitalized for probable gastrointestinal bleeding, perhaps secondary to the Celebrex; at discontinuation of this drug his pain worsened and he was re-started at a lower dose.The patient states in his letter that his oncologists have indicated his pain is related to an immune mediated reaction related to his CLL. The Health Plan has denied authorization for continued use of Celebrex on the basis that it is not medically necessary for treatment of the patients medical condition.The materials provided do not include detailed information regarding the patients clinical history or current condition. The patient states Celebrex has been recommended by his oncologists for treatment of pain associated with CLL. Review of the medical literature reveals no evidence that Celebrex will improve any manifestations of CLL. As such, Celebrex is not medically indicated for treatment of CLL. Though it is very unlikely that the patient has any clinical problems related to stage I CLL, no evidence has been provided indicating the patient requires Celebrex on other grounds, e.g., rheumatologic issues. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The representative of a now deceased male enrollee has requested intensity modulated radiation therapy for treatment of his metastatic paraganglioma.  Findings:  The physician reviewer found that intensity modulated radiation therapy is a tool that clinicians can use when there is concern about sparing normal tissues from high dose exposure. The physician determines radiation treatment parameters to maximize dose to the target and minimize dose to normal tissues. For tumors located in the posterior chest wall, intensity modulated radiation therapy is often necessary to escalate the dose to the tumor, while maintaining safe dose delivery to the spinal cord. According to an appeal letter on the said date, intensity modulated radiation therapy was chosen because of the size and location of the chest wall mass, and to minimize toxicity.  In this case, the right posterior chest wall mass appeared to abut or involve the spine. However, the dose prescribed to the target is within the accepted spinal cord tolerance.  Additionally, neither the appeal letter nor case file were explicit in describing what normal tissues were being spared with intensity modulated radiation therapy, nor what the anticipated toxicity would be without intensity modulated radiation therapy.  Conventional radiation could have been used to maintain cord tolerance and keep the lung volume receiving suprathreshold doses to a minimum. No other normal tissues are addressed in the dose-volume histogram, and there is no indication of dose escalation to the tumor.  The submitted documentation fails to establish the medical necessity of intensity modulated radiation therapy in this case.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for panniculectomy surgery. Per the American Society of Plastic Surgeons (ASPS), a panniculectomy involves the removal of hanging excess skin and fat in a transverse or vertical wedge but does not include muscle plication, neoumbilicoplasty, or flap elevation. Sachs and colleagues noted that, A panniculectomy must meet specific criteria to be medically necessary. The pannus must hang below the level of the pubis and be confirmed with photography. Patients must fail medical treatment of intertrigo for three months. Medical treatment includes good hygiene, topical antifungals, corticosteroids, and antibiotics. The role of panniculectomy is to restore normal function. Patients must maintain a stable weight for at least six months. After bariatric  surgery, patients must maintain a stable weight for at least 18 months, including the most recent six months. Based on the available documentation, this patient meets the ASPS criteria for the requested panniculectomy. The records document that the patient has lost 25% of body weight following bariatric surgery and has maintained this weight loss for several years. The provider documented the presence of a large abdominal pannus, which is demonstrated in the photographs provided for review. The patient complains of an intractable rash under the abdominal pannus. A letter from the provider reports that the patients panniculus has caused chronic intertrigo that consistently recurs over three months despite treatment with appropriate medical therapy with topical nystatin and oral fluconazole over a period of three months. The requested panniculectomy would be performed to help restore function. For these reasons, the requested panniculectomy surgery is medically necessary for treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. In this patients case, the abnormal structure of the body was due to loss of weight following bariatric surgery. The requested panniculectomy would be performed to improve function by relief of pain and intractable pruritis under the patients abdominal pannus. Moreover, the requested panniculectomy would create a more than minimal improvement in the patients appearance. Therefore, the requested panniculectomy surgery is reconstructive in nature for this patient. All told, the requested panniculectomy surgery is medically necessary and reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an UPWalker. A review of the literature does not reveal that the requested UPWalker is medically necessary for this patient. The physical examination did demonstrated that the patient is able to complete her mobility-related activities of daily living with her current assistive device. The records do not include an objective shoulder examination supporting that the patient has limitations that would not allow her to use a standard walker or rolling walker. The neurology notes indicate other than her left homonymous hemianopia the rest of her neurological examination was intact. There is no objective documentation of abnormal muscle motor strength on a physical examination in the submitted medical records. Therefore, the requested UPWalker is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with subspecialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested Adderall XR for treatment of the enrollees attention deficit/hyperactivity disorder.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  In this patients case, the documentation does not include sufficient details regarding prior trials of alternative medications.  The records do not document how these medications were less effective.  Additionally, other medication trials were not described.  The clinical documentation fails to establish the necessity of Adderall XR in this patients case.  All told, Adderall XR is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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 positron emission tomography (PET) scan with computed tomography (CT) for attenuation. While current guidelines from the National Comprehensive Cancer Network (NCCN) recommend a chest CT first, Basu and colleagues report that increasingly, integrated PET/CT imaging is playing a crucial role in the assessment of patients with known or suspected malignant pleural mesothelioma. The authors further note that the major role of PET/CT at present appears to be in the preoperative disease staging, response to treatment assessment, and post-treatment disease surveillance of mesothelioma, and that in all these three areas, PET/CT convincingly shows better results than conventional anatomical imaging alone. Therefore, PET scan with CT for attenuation is likely to be more beneficial for evaluation of the patient's condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested PET scan with CT for attenuation 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 requested service is likely to be 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 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: Medical Necessity
Decision: Upheld

The patient is a 64-year-old woman who has apparently been receiving Botox injections about twice yearly. The one included treatment note indicates a dosage of 150 U. This is within the range of doses that are currently identified as successful in treating refractory migraine. She appears to be receiving the Botox injections from a plastic surgeon.No information is submitted about any relevant clinical details other than a reported lack of success with acute treatments  analgesics, three different triptans, and Migranal. The submitted notes are from her internist, nephrologist, and plastic surgeons. There is no evidence the patient has been evaluated by a neurologist or other headache specialist. No information is given about baseline headache pattern, frequency, or impact. No evidence is given that the patient has had trials of any standard preventive medications or response to the same.At issue in this case is whether Botox therapy was/is medically necessary for treatment of the patients medical condition.This patient reportedly has migraines of unstated frequency and impact. She reportedly has not had good relief with several acute, abortive therapies. Migraines often warrant preventive therapy. There are a variety of preventive options available. Though there is evidence from randomized, double blind, placebo controlled trials that Botox is useful as preventive therapy (both for episodic and chronic migraine) and has good tolerability, standard preventives are beneficial for a large number of migraine patients. Botox is presently being used in those patients with poor response to standard preventives. Potential Botox candidates are those with disabling primary headaches with: inadequate response to conventional treatments, unacceptable side effects from existing treatment or contraindications to standard preventive treatments No documented objective evidence has been presented to suggest that this patient fits any of these criteria. The patient should be evaluated by a neurologist or other headache specialist to determine her headache pattern, review her response to standard preventives if they have been used or to initiate a trial of such agents. Based upon the information set forth above, I have determined the therapy at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 26-year-old female enrollee has requested a continuous passive motion (CPM) device and a vasopneumatic compression/cold therapy device for the treatment of her hip condition status-post surgery. Findings:  The physician reviewer found that the use of a CPM machine was not medically necessary for this patient. While early motion is a positive influence on soft tissue healing, formation of fibrocartilage, and maturation to cartilage surfaces, there is no consensus as to the application of a CPM device post-operatively, particularly in the hip joint. The hip joint is complex in that there are many planes of movement. The use of a CPM machine in terms of the design and fit of the device at the hip is more difficult than its application to simple hinge joints such as the elbow and knee. Even when a CPM machine is utilized in the simple hinge joints, there is no scientific evidence available to determine the appropriate duration of treatment, post-operatively. Although it is medically appropriate to encourage gentle passive and active range of motion in the rehabilitation of a patients hip post-surgery, better results are obtained with the guidance of a physical therapist than with the use of a CPM machine which provides only passive and not active motion. In addition, as wound healing allows, isokinetic exercise, pool therapy and kinesiotherapy represent more appropriate treatment in post-surgical patients than CPM use. With regard to the use of the vasopneumatic compression/cold therapy device, while post-operative site cooling is important and efficacious, there is no scientific evidence demonstrating that the application of the device at issue to any joint results in a better outcome than the use of conventional cooling methods. The standard ice pack method is generally accepted and utilized by most practitioners and renders a device that applies intermittent pressure and cold application unnecessary. Furthermore, the effective use of cooling to diminish edema and pain at the operative site is generally limited to the 24-hour period following surgery.
Appeal type: Experimental/Investigational
Decision: Upheld

A 43-year-old female enrollee requested authorization and coverage of the medication gleevec for the treatment of metastatic colon cancer.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that the medication gleevec is not likely to be more beneficial for treatment of the enrollees metastatic colon cancer than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested a pelvic floor stimulation home unit (CPT code E0740) for treatment of his fecal incontinence.  Two physician reviewers found that in multiple trials, patients with intact sphincter musculature benefit most from dietary modification and biofeedback. There is a lack of trials showing additional benefit with pelvic floor stimulation. In this patients case, the radiation has caused decreased compliance, thus there will be smaller volumes and a shorter time interval between sensation and the need to defecate. There is also evidence of pudendal neuropathy, which may have multiple etiologies. All told, the requested pelvic floor stimulation home unit (CPT code E0740) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: One reviewer is board certified in general surgery and is actively practicing. One reviewer is board certified in urology and is actively practicing.  One reviewer is board certified in general surgery with sub-specialty certification in colorectal surgery 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 forty-eight year-old female who was clinically evaluated for bilateral breast masses is requesting authorization of a breast MRI.  Reviewers Findings:  The reviewing physician found that this patient does not have any of the indications for breast MRI.  The reviewing physician found that he Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Uptravi. The submitted documentation supports the medical necessity of the requested medication. This patient has been diagnosed with WHO group 1 pulmonary hypertension. Uptravi is a prostacyclin receptor agonist which has been approved by the U.S. Food and Drug Administration for the treatment of patients with WHO group 1 pulmonary artery hypertension to delay disease progression and reduce the risk of hospitalization. The Health Plan has denied Uptravi and noted that the patient has not tried an endothelial receptor antagonist. The medical literature does not indicate that an endothelial receptor antagonist is indicated prior to pursuing treatment with Uptravi. There is sufficient support for the requested medication in this clinical setting. Therefore, Uptravi is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in pulmonary disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for referral to a vascular surgeon. This enrollee has prominent varicose veins and is being referred to a vascular surgeon after having tried compression stockings. The medical literature indicates chronic venous disease refers to a wide spectrum of morphologic, such as venous dilation and/or functional abnormalities, such as venous reflux of long duration.  Vein-related problems may or may not be symptomatic and include a wide range of clinical signs that vary from minimal superficial venous dilation to chronic skin changes with ulceration.  Lower-extremity chronic venous disorders encompass an entire spectrum of morphologic and functional abnormalities of the venous system. Symptoms include pain, leg heaviness or aching, swelling, dry skin, tightness, skin irritation, heaviness, muscle cramps, and itching.  Clinical signs include dilated veins, edema, lipodermatosclerosis (a fibrosing dermatitis of the subcutaneous tissue), or ulceration.  The record indicates the enrollee has prominent varicose veins on examination that are inflamed and hurt, despite compression stockings. Therefore, the requested referral to a vascular surgeon is medically necessary to treat the enrollees medical condition. 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 vascular 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 similar medical condition.