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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. Findings:  The physician reviewer found that according to the documentation submitted for review, by the date of service in question, the patient was not at risk for post-acute withdrawal symptoms. The patient was not a danger to himself or others, and he was not violent or aggressive. He showed no self-harm behaviors. There were no emotional, behavioral, cognitive, or impulsive issues requiring residential containment. He was medically and psychiatrically stable. His gout could have been treated on an outpatient basis. He was compliant and engaged in his treatment plan, and he had a sponsor. The patient was at risk for relapse as are all newly sober substance abuse individuals, however this is not an issue which meets criteria to remain in the residential setting. His symptoms of depression, anxiety, guilt and remorse could have been treated on an ambulatory basis, as could the continuation of his work on relapse prevention and the development and solidification of coping skills. This could have been accomplished at lower level of care, with concomitant community support such as a 12 step program and his sponsor.  For the reasons provided, the residential treatment center services provided during the dates of service in question were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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

A 54-year-old female enrollee has requested for a PET scan for evaluation of her abdominal pain. Findings:  The physician reviewer found that labs are sparse, and a tumor marker course is lacking. It is assumed that the patient has been referred directly to PET scan for abdominal pain, and it is impossible to ascertain whether she had an exam, a CT.
Appeal type: Experimental/Investigational
Decision: Upheld

 A 53-year-old female enrollee requested balloon sinus ostial dilation for medical treatment of her chronic sinusitis.  Findings:  Three physician reviewers found that review of the submitted documentation and relevant literature fails to support the use of balloon ostial dilation in this clinical setting. There is a lack of evidence in the medical literature that demonstrates balloon sinus ostial dilation is more efficacious than standard FESS when utilized in a patient with chronic sinus disease who has already undergone multiple sinus procedures. In such a setting the ostia may or may not already be patent and, if not, the restenosis of ostia is complicated by the presence of cicatrix and/or polypoid tissue regrowth. As such,  balloon sinus ostial is not likely to be more beneficial than any available standard therapy for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a two-year-old female enrollee has requested  for a magnetoencephalography (MEG) for evaluation of her epilepsy.  Findings:  Three physician reviewers found that the medical literature shows that MEG can assist in localizing epileptic foci, including deep ones that escape standard EEG. It can also help when MRI scans show a lesion discordant to EEG findings, and can map critical normal areas of brain function to optimize surgical planning. It is becoming a generally accepted diagnostic tool at major epilepsy surgery centers due to its ability to allow identification of deep seizure foci.
Appeal type: Urgent Care
Decision: Overturned

The parent of a six-year-old male enrollee has requested emergency services for the treatment of the enrollees condition. Findings:  The physician reviewer found that the patient was suffering pain of a sufficient severity that a prudent layperson would seek immediate medical attention due to fear of jeopardy to his health and/or bodily function.  This case is complicated by the fact that the patient had recently been treated with an antibiotic and yet had an acute exacerbation of ear pain due to infection.   It was appropriate that he was re-examined to determine the cause of his acute pain as well as rule out several other serious disorders including tympanic membrane perforation, mastoiditis, and others.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nerlynx. Nerlynx is an anti-HER2 drug that has been approved in breast cancer, but only for extended adjuvant therapy. Current studies are ongoing to assess the value of Nerlynx in the treatment of other cancers, with an attempt being made to correlate efficacy with certain HER2 mutations within a tumor cell. A study concluded that their series shows the chemosensitivity of HER2-driven NSCLC, and the potential interest of HER2-targeted agents. The authors noted that their results should help define the best therapeutic strategy for these patients and to orient future clinical trials. Overall, there is a paucity of clinical data demonstrating the safety and effectiveness of Nerlynx in NSCLC. For these reasons, the requested Nerlynx is not supported as medically necessary for treatment of this patients NSCLC. 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 internal medicine with subspecialty certification in medical 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: Medical Necessity
Decision: Overturned

A 53-year-old male enrollee requested authorization and coverage of a check up with a bariatric surgeon.  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 overturned the health plans denial on the basis that the requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a 16-year-old male enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that in terms of recovery environment, the records support a score of 3 for environmental stress. He has a moderately stressful environment. He has frequent interpersonal conflicts with his mother. Regarding environmental support, the records support a score of 3.  There is limited support in his environment.  The patients mother will participate in care through phone conversations. It does not appear other family members are involved in the care of the patient.  In terms of resiliency, the patient demonstrated a moderate response to treatment, and the records support a score of 3.  The patient has an inconsistent capacity to deal with life stressors. His recovery has been maintained for only moderate periods of time, but only with strong professional support in structured settings. He has a limited ability to follow through with treatment recommendations. In terms of acceptance and engagement, the records support a score of 2. At the initiation of treatment, the patient was obstructive with treatment. However, around the dates in question, the patient was able to develop positive relationships with his clinicians and care providers.  Thus, the patient has a composite score of 19.  Based on these criteria, the patient could have been discharged to a less restrictive environment into a partial hospitalization program during the dates of service in dispute. All told, residential treatment center services were not and are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 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: Upheld

The patient is 57-year-old female with a history of chronic low back pain, lumbar spondylosis, and degenerative joint disease. She received 122 physical therapy visits over approximately a three-year period and reports that traction helps with her pain. She would like to continue with physical therapy including traction. The Health Plan has determined additional physical therapy is not medically necessary for treatment of the patients chronic pain.Review of the submitted clinical information including the physical therapy notes and physician records indicates the patient has reached a plateau in her rehabilitation. Continued physical therapy is therefore not likely to result in any further clinical benefit. The patient can incorporate a traction unit into her home program if she so desires. Based upon the clinical information provided, there is no medical necessity for additional physical therapy in this case. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the LifeVest for treatment of his dilated cardiomyopathy.  Two physician reviewers found that based on the records provided, the patient is a 19-year-old male with a newly recognized dilated cardiomyopathy. In this circumstance, there is potential for recovery of left ventricular function over time with medical therapy. In addition, there was no indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until a period of time, about 40 days after myocardial infarction has elapsed, where continued severe left ventricular dysfunction is documented to persist despite of appropriate treatment. Placement of a prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve patient outcomes. Studies assessing the efficacy of prophylactic defibrillators early after diagnosis of myocardial infarction and reduced ejection fraction of 35% or less before ventricular function has had a chance to recover have not demonstrated improved outcome. A prophylactic wearable external defibrillator is indicated only if accepted criteria for an implantable defibrillator are met and an implantable defibrillator could not be placed, needed to be significantly delayed or required explantation. Accordingly, the LifeVest was not and 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 device 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 upheld. Credentials/Qualifications: All three reviewers are board certified in cardiology 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: Upheld

Nature of Statutory Criteria/Case Summary: An  enrollee has requested reimbursement for the pneumatic compression cooling/heating device provided .Findings:  The physician reviewer found that according to the systematic review by a study The evidence base to support the common practice of superficial heat and cold for low back pain is limited, and there is a need for future higher-quality randomized controlled trials. There is a lack of high-grade evidence-based literature to support the need for this type of iceless cold compression device after spinal stenosis surgery when superficial ice applications could have sufficed. No marginally significant benefits in analgesia, health or function would have been reasonably expected with the use of this device over independent ice application. For the reasons provided, the pneumatic compression cooling/heating device provided during the dates of dispute was 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 device 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 upheld.Credentials/Qualifications: Physician reviewers 1, 2 & 3 are board certified in physical medicine and rehabilitation and pain medicine and are actively practicing. The reviewers are all experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested for Belviq XR 20 mg, once daily for treatment of the his obesity. Findings:  The physician reviewer found that Belviq XR is approved as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index of 30 kg/m2 or greater or 27 kg/m2 or greater in the presence of at least one weight-related comorbid condition. The initial management of individuals who would benefit from weight loss is a comprehensive lifestyle intervention, including a combination of diet, exercise, and behavioral modification. Patients who would benefit from weight loss should receive counseling on diet, exercise, and goals for weight loss. When a patient with a body mass index greater than 30 kg/m2 or a body mass index of 27 to 29.9 kg/m2 with comorbidities, has failed to achieve weight loss goals through diet and exercise alone, a pharmacologic therapy is suggested.  In this case, the patient has a body mass index greater than 30 and has been enrolled in a medical weight management program for more than six months with weight loss.  The records document comorbidities including pre-diabetes and hypertension. The medical evidence supports the requested medication in this clinical setting. Final Result: The reviewers 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 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 male has requested acute inpatient detoxification followed by transitional residential recovery services for treatment of his opioid dependence.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The current guidelines do not support the services at issue in this clinical setting.  Regarding the patients request for acute inpatient detoxification, the medical records do not support these services.  This patient was motivated for treatment, and he had not pursued any treatment prior to presentation.  He had an unremarkable physical examination.  Opioid detoxification can be appropriately addressed in the outpatient setting with medications such as metoclopramide, hydroxyzine, and clonidine, which were all prescribed.  In terms of substance abuse treatment, this patient had not failed any less restrictive interventions during the course of illness, such as intensive outpatient, partial hospitalization, or supportive sober living in the community.  Considering this patients clinical presentation and current practice guidelines, acute inpatient detoxification followed by transitional residential recovery services are not medically indicated.
Appeal type: Experimental/Investigational
Decision: Overturned

A 62-year-old male enrollee has requested reimbursement for coronary computed tomography (CT) angiogram for evaluation of the enrollees irregular heartbeat.  Findings:  Two physician reviewers found that the patient has a history of multiple premature ventricular contractions (PVCs) gastro-esophageal reflux disease, polycythemia vera, deep vein thrombosis (DVT) and pulmonary emboli. He was found to have an irregular heart rhythm during routine pre-operative evaluation for foot surgery and was referred to a cardiologist. He was found to have frequent PVCs on Holter testing. An exercise nuclear stress test revealed findings that were equivocal for ischemia with upsloping ST depression and equivocal perfusion findings. He was then instructed to undergo a coronary computed tomography (CT) angiogram to evaluate whether he had any underlying coronary artery disease. The results demonstrated mild (non-obstructive) plaque. Coronary computed tomography (CT) angiography is a mature and accurate technology that is capable of imaging the coronary arteries and other cardiac structures in a completely non-invasive manner. No other non-invasive technology can provide the clarity and accuracy of coronary CT angiography. In addition, coronary CT has now been shown to have lower doses of radiation than other commonly used cardiac tests such as thallium and technetium nuclear stress tests, invasive coronary angiography and percutaneous coronary angioplasty. Coronary CT angiography has been shown to provide not only excellent clinical performance potential, but also relevant and incremental prognostic information. The American College of Cardiology (ACC) and American Heart Association (AHA) has recommended the use of coronary CT in patients with chest pain and intermediate Framingham risk. This is due to the fact that coronary CT is non-invasive and avoids complications associated with invasive coronary angiography. It also provides equal, if not better information, on the 3D geometry of coronary anatomy, coronary course in relation to other structures, plaque extent, plaque severity as well as plaque composition or morphology when compared with traditional invasive coronary angiography. This all translates into a robust technique that contains multiple important levels of clinical information in a safe, accurate and non-invasive manner in well selected patients. Coronary CT angiogram is most certainly useful as it avoids an invasive procedure with all the associated risks and complications. In addition, the study confirms the absence of coronary artery disease and allows the patient to avoid the unnecessary use of statin, aspirin and other anti-atherosclerotic medications.  All told, use of coronary CT angiography in this case is more beneficial, lower risk, and is consistent with the recommendations from the ACC and AHA.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Trulance. Researchers reported plecanatide significantly improved constipation and its related symptoms with a low rate of adverse events. These results suggest that plecanatide will be a useful treatment option in the management of chronic idiopathic constipation (CIC). In this case, the patient reported ongoing constipation over three months, without a cause identified on clinical examination or colonoscopy, consistent with chronic idiopathic constipation. The patient reported that MiraLax, laxatives, stool softeners, and Amitiza were ineffective. The medical evidence supports the requested medication in this clinical setting. Therefore, Trulance 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 gastroenterology 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 is a 37-year-old male with chronic pain syndrome. The providers notes indicated the patient was maintained on pain medications, which included one Lyrica 225mg tablet twice daily, three Lyrica 75mg tablets twice daily, and gabapentin 600mg twice daily. The records submitted indicate the patient was being treated for lumbar post-laminectomy syndrome and chronic pain. The U.S. Food and Drug Administration (FDA) approved indications for Lyrica include neuropathic pain associated with diabetic peripheral neuropathy (DPN), post-herpetic neuralgia (PHN), adjunctive therapy for adult patients with partial onset of seizures, fibromyalgia, and neuropathic pain associated with spinal cord injury. The American Pain Society (APS) guidelines state that, the efficacy of anti-epileptic drugs specifically, for radicular (or non-radicular) low back pain has not been well studied. In this case, the patient presents with chronic low back pain and has been diagnosed with lumbar post-laminectomy syndrome and chronic pain disorder. He was prescribed oxycodone-acetaminophen 10-325mg, one tablet every six hours, and Lyrica for chronic pain disorder. However, the FDA does not list chronic pain disorder as an approved indication for Lyrica. Furthermore, the APS guidelines indicate that anti-epileptic drugs such as Lyrica have not been studied for use in low back pain with or without radiculopathy. Based on these criteria, Lyrica 75mg, three (3) capsules three times daily for treatment of this patients diagnosis of chronic pain syndrome is not medically necessary. 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 anesthesiology with a subspecialty certification in pain 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.