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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation therapy. Given this patients unique clinical circumstances, proton beam radiation therapy is considered the standard of care. Given the patients young age and presence of Li-Fraumeni syndrome, she is at a heightened risk for radiation-induced toxicity, including secondary malignancy. Li-Fraumeni syndrome is known to result in increased normal tissue radiosensitivity per high quality clinical outcomes published in the peer-reviewed medical literature. It is critical to minimize the exposure to the patients right lung, heart, and uninvolved soft tissues. The provider has supplied a photon versus proton plan comparison, which demonstrates a clinically significant reduction in normal tissue exposure with the proton radiotherapy plan. Based on the treatment plan, proton radiation therapy is expected to minimize the incidence of acute and late radiation-induced morbidity compared with photon-based radiotherapy. Given the presence of Li-Fraumeni syndrome, the patients young age, and the fact that the patient is being treated with curative intent with long life expectancy, proton radiation therapy is consistent with the American Society for Radiation Oncology (ASTRO) guidelines. Thus, the requested proton beam radiation therapy is medically necessary for 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 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: Medical Necessity
Decision: Upheld

The patient is a 26-year-old male with complete T12 spinal cord injury. The patients family is requesting inpatient rehabilitation therapy. The submitted information includes no evidence of a physician request for inpatient services. Recently, the patient was noted to be independent with catheterizations, pressure relief, and upper extremity dressings. On 4/1/04, it was noted the patient required minimal assistance with lower extremity dressing. Upon discharge from the hospital, it was noted the patient required minimal assistance with self-care except for shower transfers. The physical therapy evaluation of 3/27/04 indicated the patient required moderate assistance for bed mobility, supine to sit, and toilet. The patient apparently needed assistance to get his legs off bed for sliding board transfer. The patient appears to be safe at home with assistance from caregivers. A request has been made for inpatient rehabilitation therapy. The Health Plan has denied the request on the basis that additional inpatient therapy is not medically necessary.An inpatient rehabilitation program is not medically necessary for the patient to achieve goals of independent function. The patient appears to be safe at home with assistance from caregivers. It is not necessary that the patient be independent to be a candidate for in-home rehabilitation therapy. It is only necessary that the patients caregivers be able to safely care for him. With continued in-home or outpatient rehabilitation therapy the patient is likely to achieve independence with transfers and bed mobility. Based upon the information set forth above, I have determined that the requested therapy is not medically necessary. Therefore, the Health Plans denial should be upheld. However, based upon the submitted records it appears the patient requires a more intensive in-home rehabilitation program than he has been receiving.  The patient should receive at least three hours a day of in-home rehabilitation therapy with a dedicated team approach to therapy. The outpatient day treatment previously recommended by the Health Plan would be a safe and appropriate alternative.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Cytogenic Microarray testing for copy number variation and Preimplantation Genetic Diagnosis testing for evaluation of her medical condition.  Three physician reviewers found that the use of microarray analysis screening in obstetrics has several applications.  The most common application is use in the prenatal post implantation setting.  Recently, it has also been used in certain situations for preimplantation diagnosis.  In this patients case, the limited history provided does not indicate a history of inheritable genetic disorders.  The chart does not give a history of repeatedly failed in vitro fertilization cycles.  Without this technology, this patient would essentially face risks inherently associated with pregnancy similar to that of any other patient of the same age with a spontaneous conception.  At this time, the superior efficacy of the services at issue has not been established. Final Result: Three 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: All three reviewers are board certified in obstetrics and gynecology 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: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested acupuncture services for treatment of her ulcerative colitis. Findings:  The professional medical reviewer found that although the patient reports that treatments have improved her health dramatically, there is no objective substantiation of this in the progress notes or other evidence submitted. The patients pain level is consistently reported as low severity and on the Summary of Clinical Treatment form is listed between 6 and 8 on an analog scale of 0-10.  Based upon the information set forth above and review of all available case file documentation, there is no evidence the acupuncture treatment in question was curative in nature. Rather, it was for the purpose of maintenance as the patient appears to have plateaued with treatment and is being seen approximately once weekly without any measurable improvement in her symptom or complaints.
Appeal type: Experimental/Investigational
Decision: Upheld

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 submitted documentation fails to demonstrate the superior efficacy of the services at issue.  This patients screening examination noted an area of suspicion in the one breast.  Coned compression spot films and ultrasound of the area in question were appropriate.  However, the addition of breast tomosynthesis to evaluate an area of concern already to be evaluated by compression spot films and ultrasound was likely of no added benefit to the patient since the area of concern had already been identified.  In sum, breast tomosynthesis was not likely to have been more efficacious than other methods of evaluating this patient.  Final Result: Two 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:  All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for substance abuse detoxification and residential treatment center services received. Findings:  The physician reviewer found that at the time of admission to detoxification and then residential level of care, the patients vital signs were stable and the patients scores were in the mild range. The patient was not receiving medications to manage withdrawal symptoms. The patient in this case had no documentation of active withdrawal symptoms, unstable vital signs, ongoing need for medical monitoring, suicidal or homicidal ideation, aggression, self-injurious behavior, non-response or adverse response to medications, difficulty with attending to activities of daily living, dangerous or non-supportive recovery environment, or repeated failure of treatment at lower level of care such as intensive outpatient programs or partial hospital programs which would support treatment at the detoxification and/or residential level of care.  Research has shown that intensive outpatient programs for alcohol and drug use disorders can be as effective as inpatient treatment for most individuals seeking care. Based on the clinical documentation provided and current medical literature, the patient's admission to detoxification and residential level of care was 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 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

A 52-year-old female enrollee requested authorization and coverage of the medication Zestril. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees hypertension.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old male enrollee has requested facial augmentation surgery for treatment of his lipoatrophy. Findings:  The physician reviewer found that although the proposed soft tissue filler injections are not required to treat a physiologic functional problem, they are appropriate from a reconstructive standpoint. The American Medical Association (AMA) defines reconstructive surgery as surgery performed on abnormal structures of the body caused by congenital deformity, trauma, infection, tumors or disease. The AMA notes that reconstructive surgery is generally performed to improve function, but may also be done to approximate a normal appearance. Based on this definition, which is consistent with California law regarding reconstructive surgery, the proposed injections are reconstructive to correct an abnormal structure of the body resulting as a consequence of a disease (HIV) and to restore the patient to a more normal appearance. The FDA has approved Sculptra as a treatment to correct HIV-induced lipoatrophy, and this particular proposed treatment is reasonable to try to correct a deformity that is secondary to an illness.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 12-year-old male enrollee has requested growth hormone (GH) therapy for the treatment of the enrollees short stature. Findings:  The physician reviewer found that a normal IGF-1 level argues against a diagnosis of GH deficiency. The record indicates that the height of the patient was 52.75 yielding an adult height prediction of 66 to 67.4 by the Greulich and Pyle Atlas tables for (bone age) retarded boys. From the clinical information provided, a diagnosis of constitutional delay appears probable and the adult height prediction is within the normal range.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz 10 mg tablets. The records provided for review document that this patients alopecia areata has been uncontrolled with standard steroid regimens. The provider charted complaints of chronic eye irritation and inflammation. Without eyelashes, which function to prevent debris from damaging the eye, the patient reports chronic eye irritation and inflammation. This also increases the patients risk of developing vision problems. To manage her symptoms, the patients provider recommended treatment with Xeljanz. For challenging patterns of alopecia areata, one safe and effective treatment option is Xeljanz. Researchers noted that Xeljanz doses can be up-titrated to 10 mg twice daily to achieve the desired therapeutic response. Researchers evaluated 90 patients with severe alopecia areata treated with Xeljanz. The authors reported that 77% of patients showed evidence of clinical response without serious adverse events. In the most recent Alopecia Areata Consensus of Experts, 30 experts agreed that janus kinase (JAK) inhibitors can be an effective monotherapy in the treatment of severe alopecia areata. Given these findings, the requested Xeljanz 10 mg tablets are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Xeljanz 10 mg tablets are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication 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 dermatology 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: Urgent Care
Decision: Overturned

The parent of a two-year-old female has requested for hospital services and follow-up office visits.  Findings:  The physician reviewer found that Kawasaki disease (KD) is an idiopathic vasculitis defined by a constellation of clinical signs supported by certain laboratory data. The principal cause of death is myocardial infarction caused by thrombosis of coronary artery aneurysm or thrombosed coronary arteries. The treatment for KD is intravenous immunoglobulin given within 10 days of the onset of symptoms. This is supplemented with the use of aspirin or other anti-inflammatory medications. Patients require evaluation with an electrocardiogram as well as an echocardiogram. Prompt diagnosis and treatment can prevent coronary artery aneurysm in 95% of patients. Kawasaki disease is a medical emergency.
Appeal type: Medical Necessity
Decision: Upheld

The patient is an 18-year-old female with the reported onset of eating disorder behaviors at the age of 14. She was diagnosed with bulimia nervosa and described as having a bad body image with binging and purging behaviors once per day during her most acute period. The record indicates she had not been binging or purging with any regularity since her discharge from the intensive inpatient program in October 2004. The patient did admit to urges to restrict her intake approximately three times per week, however she denied over-exercising, using laxatives or diuretics or water loading. Her admission weight was 139.8 pounds in February 2005; her estimated ideal body weight being between 134 and 142 pounds.  The patients treatment course was generally unremarkable, and she received Prozac 40mg per day in addition to a variety of therapies. The patients discharge weight was 139.2 pounds. The patients parent has requested reimbursement for residential treatment services provided from March 2005 through April 2006. The Health Plan denied the request based upon a determination that the services were not medically necessary.The progress notes indicate the patient was compliant with her treatment program despite some irritability and a somewhat challenging attitude. She was not actively binging and purging either before or during her residential treatment stay, and her weight was entirely stable.  There is nothing in the clinical record to indicate that her condition warranted a level of care with 24-hour supervision beyond March 2005. Therefore, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee has requested detoxification, substance abuse subacute/residential treatment center (RTC) services for treatment of his substance use disorder.  Findings:  The physician reviewer found that the records do not indicate that that this patient was previously enrolled in structured treatment or a lesser level of care for his alcohol dependence prior to his admission on the date in question. The providers notes suggest that the patient was stable and not experiencing any significant symptoms of withdrawal almost 2 weeks later when he was admitted to the treatment facility. The patients medications administered for depression were not altered during treatment and he was treated with a standard recovery based 12-step oriented 28-day treatment model. In general, patients with this degree of severity are usually safely and effectively managed at a partial hospital program (PHP) level of care. This patient could have received sufficient medical and nursing care for his depression and medications, and could be monitored for any post-acute withdrawal issues. For these reasons, the residential level of care services provided this patient on the dates in question have not been established as medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for fecal analysis. Findings:  Three physician reviewers found that fecal calprotectin testing has been recognized as an accurate method to assess the likelihood of a child having inflammatory bowel disease, without the discomfort and need for sedation which a colonoscopy entails.  It is used both clinically and in research studies as a marker of intestinal inflammation. In a single-center study, calprotectin was found to be far superior to commonly utilized blood parameters such as C-reactive protein and white cell count. There is sufficient support for the services at issue in this patients case. Therefore, fecal analysis was likely to be of greater benefit than other methods of evaluating this patient.Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in pediatrics with sub-specialty certification in pediatric 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 45-year-old male enrollee requested authorization and coverage of metal on-metal surface replacement hip surgery for treatment of vascular necrosis at the hip.  The health plan denied the enrollees request indicating that the requested procedure is not medically necessary.Three physician reviewers performed a medical necessity Independent Medical Review.  All three physician reviewers upheld the health plans denial on the basis that the requested surgery is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Tasigna 300 mg twice daily. This patient has an atypical chronic myelogenous leukemia that is PDGFR alpha positive with hypereosinophilia, similar to a hypereosinophilic syndrome. Medical literature states that hypereosinophilic syndrome is characterized by sustained overproduction of eosinophils and organ dysfunction. The authors studied Tasigna in a phase 2 trial that included 12 patients with hypereosinophilic syndrome, and were able to follow-up with seven patients. On follow-up, the study concluded that Tasigna was effective in four patients, including one patient who achieved complete hematologic response. In addition, Tasigna demonstrated a safety profile consistent with other studies. This patient demonstrated hematologic response with imatinib, but was intolerant to this agent due to toxicity. As noted by the provider, Tasigna is an alternative for imatinib. Tasigna is a reasonable next line of therapy for treatment of atypical chronic myelogenous leukemia-type disease. Given this support, the requested Tasigna 300 mg twice a day is medically necessary for 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 subspecialty certifications in medical oncology and hematology 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 25-year-old female enrollee has requested reimbursement and prospective authorization and coverage for residential treatment level of care from a specific date and forward for treatment of the enrollees bulimia nervosa. Findings:  The physician reviewer found that the American Society of Addiction Medicine (ASAM) and the American Psychiatric Association (APA) clinical practice guidelines recommend residential treatment for patients who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. Based on review of the available records, residential placement was recommended by the patients providers who know the patient has not yet integrated the sustained learned behaviors or consolidated the treatment gains necessary to break the negative schemas, pathological symptom complex and self-defeating coping strategies which keep her from succeeding in the community. Further, the patient had previously failed treatment in a less restrictive setting and poses an imminent risk that her complex psychosocial stressors will produce enough distress to undermine treatment in a lower level of care. As such, discharge from residential level of care would place the patient at risk for acute hospitalization. Accordingly, residential treatment services were and are medically necessary for treatment of the patients medical conditions and should be covered from the date in question and forward.