Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for services. Based on the submitted medical documentation, this patient did not receive emergency medical services. The patient was diagnosed with low volume intermediate risk prostate cancer. This type of prostate cancer is a slow growing cancer and can also be managed with active surveillence in some patients. The current medical literature does not support that the treatment outcomes are better if the disease is managed on an emergent basis. The patient was offered an appointment with an in-network provider. The patient did not follow-up on the recommendations of the Health Plan and decided to undergo surgery with an out-of network provider. The records do not document acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy, serious impairment to bodily functions and/or serious dysfunction of any bodily organ. Therefore, the services at issue were not necessary for the treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services.Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Corlanor (5 mg tablet twice a day). Findings:  The physician reviewer found that ivabradine is safe and effective in significantly improving heart rate and quality-of-life in patients with hyperadrenergic POTS as the predominant subtype. In this case, given the patients confirmed diagnosis of POTS improvement with Corlanor, the requested medication is medically indicated. Therefore, Corlanor (5 mg tablet twice a day) 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 cardiovascular 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: Upheld

A 25-year-old female enrollee has requested inpatient treatment and pain monitoring at a dual diagnosis treatment facility for treatment of her behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, this patient evidences dramatic symptoms of parasuicidality and affective illness interwoven with her underlying characterological organization and polysubstance use in context of unrelenting pain. She has been unable to generate any therapeutic momentum with her current treatment regimen. Based on the most recent notes, the patient did not require acute psychiatric level of care services. She indicated that her pain was the primary issue of concern. Her recent bouts of attention-seeking self-injurious behavior were the result of desperation and poorly refined defenses consistent with the borderline personality organization. Considering the patients tenuous home environment and formidable symptom complex that has not responded to an array of multidisciplinary interventions, a residential admission focusing on her addictions and chronic pain would be safe, appropriate and reasonably expected to improve her condition while preventing a more serious episode of illness. All told, the records support the medical necessity of residential treatment services for management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent/conservator of a 26-year-old male enrollee has requested for titration and individual cognitive therapy for treatment of the enrollees schizophrenia. Findings:  The physician reviewer found that antipsychotic medication has been the standard of care for those afflicted with a formal thought disorder, such as schizophrenia, since the 1950s (Kreyenbuhl, et al.). A recent paper by Lieberman noted that, We currently have 20 marketed antipsychotic drugs available for use, which form the cornerstone of our treatment for schizophrenia. In this particular case, the use of Risperdal is consistent with the standards of good medical care in the United States.  If the patients response has been sub-optimal on that particular medication, it would be reasonable to cross-taper to one of the other FDA approved antipsychotic medications in a systematic and structured fashion.Cognitive behavioral therapy (CBT) has shown some promise in the treatment of schizophrenia, particularly in the United Kingdom (Turkington, et al.).  However, there are mixed reports in the literature (Turkington, et al.; Morrison; and Dixon, et al.), and the patient populations that tend to have the best outcomes include females, those with a short duration of illness, and those with less intense symptomatologies (Morrison).  Patients with poor insight or acceptance of their illness, profound negative symptoms or delusional complexes are difficult to engage and treat with this modality (Morrison). The Schizophrenia Patient Outcomes Research Team (Dixon, et al.) made several recommendations in 2009 after examining the peer-reviewed literature. CBT was one of the recommendations, along with several other interventions, such as Assertive Community Treatment, Supported Employment Skills Training, Token Economy Interventions and Family-Based Services.  The patient presented in this case does not have strong positive predictive indicators for CBT, and there are other non-pharmacologic interventions supported in the literature.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested continuous positive airway pressure (CPAP) supplies for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the equipment at issue.  The use of home, unattended, sleep studies does not contribute to the management of patients.  Even if the apnea-hypopnea index (AHI) reported is correct, there is no data on the position of sleep.  Thus, in this case, positional obstructive sleep apnea is not ruled out.  The use of CPAP may not be indicated for patients with positional obstructive sleep apnea.  In order to demonstrate the need for CPAP and supplies, a facility-based sleep study with a certified attendant must document that the patient met criteria for the medical necessity of treatment with CPAP and the optimal setting of CPAP used.  Based on the documentation provided for review, the equipment at issue was not and is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the equipment at issue was not and 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing. Findings:  The physician reviewer found that the records provided for review document that this patient has a family history of coronary artery disease and diagnoses of mixed hyperlipidemia, low high-density lipoprotein (HDL) cholesterol, mild obstructive sleep apnea (OSA), low serum vitamin D, elevated liver enzymes, and essential hypertension. The patient underwent evaluation with advanced lipoprotein testing. In this circumstance, guidelines for the management of cardiac risk established by the American College of Cardiology (ACC) and American Heart Association (AHA) do not support routine advanced lipoprotein testing (Stone, et al.). These guidelines currently do not recommend performance of specialized tests in the context of assessing coronary risk including lipoprotein associated phospholipase A2, sub-classifications of low-density lipoprotein (LDL) cholesterol, HDL cholesterol subclasses, lipoprotein (a), and homocysteine. In addition, treatment changes or additions based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. All told, the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and adult congenital heart disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is 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 64-year-old female enrollee requested authorization and coverage for an ERCP with Bilary manometry by an out-of-network physician for the treatment of chronic abdominal pain after a cholecystectomy performed 1997.  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 it is not medically necessary for the patient to obtain the requested services from a non-contracted provider.
Appeal type: Medical Necessity
Decision: Upheld

A 24-year-old female enrollee requested authorization and coverage of gastric banding. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation therapy. There is insufficient data to suggest treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. In a multi-institutional analysis of 1850 patients with low or intermediate risk prostate cancer, Vapiwala and colleagues found no significant difference in gastrointestinal or genitourinary toxicities between patients receiving hypofractionated intensity-modulated radiation therapy (IMRT) and those receiving proton beam therapy. The authors further found no difference in disease control between the two modalities. The American Society for Radiation Oncology (ASTRO) states, Proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry. The National Comprehensive Cancer Network (NCCN) guidelines for the treatment of prostate cancer do not note a clear demonstrated benefit of proton therapy over standard treatment. Given that conventional radiation therapy techniques are associated with a high level of safety and efficacy, the requested services are not medically indicated. Therefore, proton beam radiation therapy is not medically necessary 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 radiation oncology 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

A 36-year-old female enrollee has requested Genotropin for treatment of her medical condition. Findings:  Three physician reviewers found that the medical records submitted do no support the diagnosis of GH deficiency in this patient, and there is no evidence submitted to support other pituitary hormone deficiencies. The patients low thyroid stimulating hormone (TSH) level is likely due to the thyroid hormone she is taking. Furthermore, based on the submitted records, this patients prior hysterectomy (surgical menopause) cannot be ruled out as the cause for her low luteinizing hormone (LH) and follicle stimulating hormone (FSH) levels. This is evidence against the suggestion of pituitary dysfunction. This patients endocrinologist feels that an MRI is contraindicated for this patient because she has a prolactinoma. However, according to the submitted records, the only finding suggestive of a pituitary problem is an elevated prolactin level (171-215). Because this patient is on medications for her eating disorder, it is not possible to rule these medications out as the cause of her elevated prolactin levels (Molitch). Lastly, this patient has normal growth hormone levels and although she had low-to-normal IGF-1 levels, patients with an eating disorder commonly exhibit such low levels.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for panniculectomy for treatment of a symptomatic abdominal pannus as a result of significant weight loss.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity for the requested procedure in this clinical setting. This patient had undergone significant weight loss following bariatric surgery.  She has evidence of a symptomatic abdominal pannus as a result of her significant weight loss.  Her symptoms have included chronic rashes and back pain.  She has attempted typical dermatologic treatment, which has not been able to control her rashes and boils.  The submitted photographs support her clinical scenario of functional impairment related to the pannus. There is evidence of a severe lower abdominal pannus that hangs below the pubic bone. In this patients case, there is sufficient detail in the medical documentation to support that there are functional problems related to her lower abdominal overhang. She has chronic rashes that have failed to resolve with typical dermatologic treatment.  Therefore, the requested panniculectomy is medically necessary for treatment of this patients medical condition.  In this patients case, the lower abdominal overhang is an abnormal occurrence, because of the previous weight loss. The weight loss was the cause of the abnormal presentation. The requested panniculectomy will relieve her functional problems from chronic rashes and back pain. Accordingly, panniculectomy would be expected to provide more than a minimal improvement in the appearance of this patient. As such, the requested panniculectomy is reconstructive in nature. Final Result: The reviewer determined that the requested procedure is medically necessary and is reconstructive in nature 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for physical therapy. Findings:  The physician reviewer found that  in this case has experienced chronic, persistent symptoms following remote head traumas. She has undergone vestibular rehabilitation without objective clinical benefit in the past and more recently with some subjective benefit reported. Based on the records provided for review, the patient has undergone sufficient rehabilitation to be independent with a home exercise and self-management program to further improve her balance, endurance, and activity tolerance. The provider noted that the patient is able to exercise on her own without difficulty, and she is participating in a yoga program focused on a history of brain injury. While she has ongoing symptoms, there is no reasonable expectation that additional physical therapy will result in any significant, sustained benefit with respect to health or functional outcomes over an independent program. Most patients recover from concussions within a short interval. Persistence of symptoms beyond the generally accepted time frame for recovery is referred to as post-concussion syndrome (Leddy, et al.). The mainstays of treatment for concussion and post-concussion syndrome are an appropriate period of rest, gradual return to activities, and self-management strategies. Some rehabilitation interventions in the early setting have been shown to be effective in addressing functional concerns, but the effectiveness of rehabilitation measures, including long-term individualized rehabilitation for post-concussion syndrome, are not possible based on the available peer-reviewed medical literature. The evidence base related to the effectiveness of vestibular rehabilitation for post-concussive dizziness is limited and precludes conclusions to support its efficacy. Given these findings, the requested physical therapy is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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 45-year-old male enrollee has requested a queen size adjustable electric bed for treatment of his cerebral palsy, hiatal hernia and gastroesophageal reflux disease. Findings:  The physician reviewer found that gastroesophageal reflux disease is common in individuals with cerebral palsy and can result in significant complications. Swallowing difficulty, contracture and musculoskeletal pain are also frequently associated with cerebral palsy. Proper bed positioning is extremely important in this patient population to reduce the risk of these and other associated medical complications. In the case under review, the patient has cerebral palsy with gastroesophageal reflux disease, contractures, spasticity, muscle weakness and limited mobility. Given his multiple impairments and comorbid conditions, he requires special positioning and frequent repositioning in order to minimize the risk of further serious complications. The requested queen size adjustable electric bed is medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene panel testing for evaluation of the enrollee, who reported dizziness and palpitations. Findings:  Two physician reviewers found that per the records, this patient had some coronary risk, but no documented coronary disease. In this circumstance, guidelines for assessing the likelihood of obstructive coronary disease, managing cardiac risk and evaluating potential cardiac symptoms are published, periodically updated by expert national committees, and endorsed by several national organizations. These guidelines currently do not recommend the routine use of gene expression testing to help assess the presence of coronary disease or the risk for developing coronary disease.  Although the testing performed has promise with respect to assessing risk of obstructive coronary disease, there is a lack of data to indicate that a change in treatment based on these test results favorably affects cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling including basic lipid analysis. At this time, there is insufficient clinical outcomes evidence from well-conducted trials supporting the services at issue. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are 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.