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

The patient is a 64-year-old male with end-stage renal disease and myelofibrosis with a difficult to control anemia. His anemia was most likely related both to end stage renal disease and myelofibrosis. The patient has been maintained on dosages of Procrit in the range of 60,000 units three times a week. In addition, the patient received 150 mcg of Aranesp per week. A request has been made for reimbursement for dosages of Procrit in excess of 60,000 units per week and dosages of Aranesp in excess of .45 mcg/kg per week that were received while the patient was traveling abroad. The Health Plan has denied this request indicating that the dosages the patient received exceeded the recommended amounts and therefore, were not medically necessary.The patients nephrologist indicates the patient has responded only to large doses of erythropoietin (Procrit). As such, it was quite reasonable to continue to treat him with increased dosages of Procrit while he was out of the country. However, there is no justification in the submitted materials for the increased dosage of Aranesp the patient received while in Germany. There is no evidence that increased dosages of Aranesp are any more effective than the recommended dosage. Furthermore, it is not clear that combining Aranesp and Procrit is beneficial. As such, the increased Aranesp dosages were not medically necessary for this patient.Based upon the information set forth above, I have determined that although the increased dosages of Procrit were medically necessary for treatment of your medical condition, the increased dosages of Aranesp were not medically necessary for treatment of your medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Urgent Care
Decision: Overturned

A 67-year-old male enrollee has requested emergency services for the treatment of his condition. Findings:  The physician reviewer found that the patient presented for emergency medical care due to abdominal pain, rectal protrusion and inability to move his bowels for several days.  The differential diagnosis for these symptoms includes bowel obstruction, fecal impaction, diverticulosis, rectocele, and other potentially serious disorders.  A prudent layperson suffering from these acute symptoms and significant pain would appropriately seek immediate medical attention out of fear of jeopardy to his health and possible injury to bodily organ function.  Without immediate medical evaluation, diagnostic work-up and specific therapy, the patients condition would not likely improve.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old female enrollee requested authorization and coverage of a gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a nine-year-old enrollee has requested intensive outpatient rehabilitation program for treatment of the enrollees stroke with left-sided hemiplegia. Findings: The physician reviewer found that based on the documentation submitted for review, the patient has a history of an ischemic stroke of hemispheric subcortical origin. Intensive rehabilitation therapy as an outpatient to stabilize and recover neurologic function is medically necessary. Intensive physical and occupational therapies are the standard of care in this clinical setting. The specific treatment provided by the Kennedy Krieger Institute that includes pediatric rehabilitation, physical therapy, occupational therapy, neuropsychology, is medically necessary to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes. All told, the requested intensive outpatient rehabilitation program at the frequency of five days per week for four weeks has been established as medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are 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 neurology with special qualification in child neurology 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 56-year-old female has requested Neulasta injections for treatment of her neutropenia.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication in this patients case.  Chronic lymphocytic leukemia is associated with autoimmune disorders such as thrombocytopenic purpura, autoimmune hemolytic anemia and autoimmune neutropenia.  The hemolytic anemia also has an association with the use of fludarabine.  Autoimmune hemolytic anemia is treated with glucosteroids and stronger immunosuppressive agents such as azathioprine.  Azathioprine is known to cause bone marrow suppression, which may require growth factor support.  The use of Neulasta for azathioprine-induced neutropenia is medically necessary and is the standard of care in this clinical situation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for orthotic shoe inserts for right and left feet. Findings:  The physician reviewer found that Fong and colleagues note that it is a routine practice to prescribe a combination of rocker shoes and custom-made foot orthoses for patients with plantar fasciitis. In this case, the patient reports painful plantar fasciitis and having flat feet since birth, a condition which may cause and/or exacerbate plantar fasciitis pain. Given that custom orthotics are routinely used to treat plantar fasciitis, and that this patient has reported relief using them in the past, custom orthotics are medically indicated for this patient. Therefore, orthotic shoe inserts for right and left feet are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 podiatry 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 parent of an enrollee has requested residential behavioral health services for treatment of the enrollees Aspergers disorder and anxiety disorder.   The physician reviewer found that this patient has a long history of behavior problems and his history reveals that a death in his family has caused him to decline significantly from his previous level of functioning. His problems are not amenable to a short-term solution, such as an acute hospitalization. This is reflected in his diagnoses of Aspergers disorder which indicates longstanding problems, combined with a new diagnosis of major depressive disorder precipitated by his fathers death. As noted in the medical literature, residential treatment is appropriate when a patient demonstrates chronic maladaptive behaviors that need more structure than can be provided in a less restrictive setting such as partial hospitalization program (PHP) or intensive outpatient program (IOP) levels of care. This patient has chronic maladaptive behaviors that prevent him from functioning in society. Specifically, he is refusing to attend school, and is unlikely to comply with attendance in PHP or IOP treatment. The only treatment setting that provides staff who can regulate this patients sleep patterns, wake schedule and monitor his socialization is a residential treatment setting. Consistent with these findings, the residential behavioral health services are supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were and are 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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 15-year-old female with longstanding difficulties with self-mutilation, suicidal statements, distractibility, short attention span, restless and intrusive behavior, impulsivity, and excessive anger and aggression that was admitted to a residential treatment center in January 2005. She participated in a variety of therapies and was medically managed with Strattera, Seroquel, and Prozac with no apparent adjustment in medication dosages. The facility records indicate the patient was initially quite hostile and aggressive. For example, in February 2005 she and another resident left the facility AWOL and thereafter she was combative with staff, attempting to hit them with a metal bar. At other times, she was described as agitated and disrespectful to staff. Her behavior and demeanor seemed to improve during March and early April 2005, but the improvement was not sustained.  In April 2005 it was noted that she was very agitated and disrespectful to staff during class. She is still not completing her schoolwork. She has made threats to show staff how bad she can really be, making more threatening statements to peers, continues to sneak things into her room. Therapist reports that she is very hateful and even made threatening statements to therapist. In April 2005, she was described as agitated and volatile, giving the impression that she is on the verge of physical aggression. Unmotivated and fairly unworkable at this time.  The patients parents dispute the Health Plans denial of coverage due to a lack of medical necessity, and have requested reimbursement for the treatment interim from March 2005 through May 2005.The patient has a longstanding history of aggressive and impulsive behavior. The staff notes through April 2005 point to a continuance of those behaviors. The patient stating that she is doing well, is not particularly compelling and doubtfully ought to be taken at face value. Clearly, her sense of how she is faring is not consonant with the staffs perspective. Considering the context of her persistent aggressiveness as documented in the submitted treatment notes, continued residential treatment was indicated through May 2005. All told, I have determined the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old female enrollee has requested artificial disc replacement surgery for treatment of her lumbar disc degenerative disease (with radiculopathy). Findings:  Three physician reviewers found that the possibility of clinically relevant increased adjacent segment degeneration following fusion, although not definitively established, has led to interest in artificial disc replacement to preserve motion. However, the efficacy of these implants over time has not been established (Resnick and Waters). Although short-term results have been encouraging, the need for further long-term randomized studies has been noted (Tropiano and colleagues). This was recognized in the initial 2006 approval by the FDA, which required further study over time following the approval of the procedure. Tools for collection of data have been established (Schluessmann and colleagues), and studies are in progress, but the results are not yet available. The efficacy of replacement and motion-sparing technology has not yet been demonstrated (Madigan and colleagues) sufficiently in the medical literature. All told, there is inadequate scientific evidence to support the efficacy of artificial disc replacement for treatment of lumbar disc disease.
Appeal type: Medical Necessity
Decision: Upheld

A 26-year-old female enrollee has requested biofeedback therapy for the treatment of her abdominal pain. Findings:  The physician reviewer found that there is limited objective scientific data available regarding the use of biofeedback for the treatment of IBS. Although there is some evidence that behavioral therapies, one of which is biofeedback, may have some benefit in IBS, this evidence is limited and limited in its objectivity. In addition, there is limited evidence that biofeedback may be helpful in treating IBS with constipation.  Also, there is little evidence that biofeedback may assist with completion of evacuation of stool. In general, the efficacy of biofeedback therapy for the treatment of IBS is not supported by peer-reviewed data. The patients primary care provider has suggested a course of counseling/therapy, which is a reasonable medical recommendation at this point.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old male enrollee has requested proton beam radiation therapy for treatment of his prostate cancer.  Findings:  Three physician reviewers found in the peer-reviewed medical literature, Yu and colleagues noted that proton radiotherapy is an emerging treatment for prostate cancer despite limited knowledge of clinical benefit or potential harms compared with other types of radiotherapy. The authors concluded that proton radiotherapy did not provide a difference in toxicity at one year follow-up when compared to intensity modulated radiation therapy (IMRT). Overall, comparative studies have not demonstrated a safety or survival benefit when proton beam therapy is compared to IMRT in the treatment of prostate cancer. Given the lack of scientific support for the use of proton therapy over IMRT, the requested therapy is not likely to be more beneficial for treatment of this patients prostate cancer than standard available therapies.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested a computed tomography (CT) scan of the sinus for an evaluation of her sleep apnea, bruxism and temporomandibular joint (TMJ) dysfunction. Findings:  The physician reviewer found that there is a scarcity of scientific literature supporting the use of static CT scanning as being efficacious in determining treatments and predicting outcomes in patients with OSA.  While real-time nonstatic studies do appear to yield useful information, optical coherence tomography and computer assisted video-endoscopy are still largely investigational.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old female enrollee has requested continued acute care stay for the treatment of her stage IV right breast carcinoma, metastatic to the bone. Findings:  The physician reviewer found that the patient underwent L3 to L5 laminectomy, resection of L4 inferior and partial superior facet joint, resection of pedicle tumor, dissection of lateral mass transverse process tumor right-sided, resection of L3 joint cyst lateral recess, decompression bilateral L4-5, posterior segmental fixation L3 to L5, posterior autologous bone graft and neural monitoring. This is a major spinal surgery which requires a substantial inpatient stay to achieve and maintain independent function. During the dates of service at issue, the patient was being transitioned from intravenous patient-controlled analgesia to oral pain medicine and required continued monitoring to determine if independent functioning and other capabilities remained. Thus, the acute care services provided were within generally accepted standards in this setting and medically appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned

A female enrollee requested magnetic resonance imaging (MRI) of the left breast for medical evaluation of her left nipple discharge.  Findings:  Two physician reviewers found that the requested MRI of the left breast is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Nipple discharge is the third most common breast complaint after breast pain and breast mass (Hussain, et al). Lubina and colleagues prospectively evaluated 56 breasts of 50 consecutive patients with nipple discharge who had inconspicuous mammography and ultrasound using breast MRI. The authors concluded that MRI of the breast is an accurate imaging test and can replace galactography in the work-up of nipple discharge in patients with inconspicuous mammography and ultrasound. Thus, the medical literature supports MRI of the breast for patients with nipple discharge despite inconspicuous mammography and ultrasound.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old male enrollee has requested speech therapy for the treatment of the enrollees condition. Findings:  The physician reviewer found that the child was profoundly language-delayed by the age of two. Speech pathology evaluation was clearly one of the mandatory primary evaluations. The licensed speech pathologist found a near absence of developed language. Childhood speech delay has many possible etiologies. This child was considered intellectually normal, had no obvious genetic or familial disorder, and the language delay was diagnosed as being due to a neurological dysfunction of the childs expressive language cerebral center. Labeling the childs language delay as apraxia was an unusual diagnosis, as apraxia is a motor malfunction of the oral-facial musculature and is generally utilized in adult neurology to describe damage from small strokes. A more meaningful diagnosis would be developmental expressive aphasia. The childs language delay is clearly neurological due to failure of his cerebral speech development, and the referral was appropriate. The treatment was medically indicated and appropriate for the child to develop speech by school age.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: Enrollee has requested reimbursement for the catheterization and coronary artery stent placement performed on 2/27/18. Per American Heart Association (AHA) criteria, cardiac catheterization is medically necessary for patients with intermediate or high-risk factors. High risk factors include diabetes, coronary artery disease (CAD) with prior myocardial infarction (MI) and hyperlipidemia. The AHA further indicates that stent placement is medically necessary for patients with diabetes, the presence of which increases risk of MI and percutaneous coronary intervention (PCI). Here, the patient has a medical history including high-risk factors such as diabetes, hyperlipidemia and CAD with prior MI. The patient therefore meets AHA medical necessity criteria for both cardiac catheterization and stent placement.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and I am actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old male enrollee has requested intensity modulated radiation therapy (IMRT) for treatment of his recurrent prostate cancer.  Findings:  Three physician reviewers found that this young patient with recurrent prostate cancer has been determined to have no distant disease and has been found to be a candidate for local therapy to the prostate bed with IMRT. The recurrent disease is of close proximity to the bladder and rectum. In addition, after a prostatectomy the small and large bowels sometimes adhere to the pelvis and may be exposed to high doses of radiation. With this concern, IMRT has been shown in the available literature to offer better control enabling delivery of high doses to the target area while avoiding the neighboring sensitive organs and tissue. Nutting and colleagues found that IMRT may reduce side effects in patients and allow modest dose escalation within acceptable complication rates. Therefore, the requested therapy was appropriately recommended and should be approved for further management of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for Intensive Care Unit (ICU) services. Findings:  The physician reviewer found that the submitted records partially support that the services at issue were medically necessary. In this case, the patient presented with a submassive pulmonary embolism, for which he underwent catheter-directed thrombolysis treatment with EKOS. This treatment option was reasonable based on the current medical evidence and clinical practice guidelines. This treatment necessitated ICU level care on the first date of service, given the presence of pulmonary artery catheters, which required close monitoring and strict positioning of the patient flat in bed. The catheters were removed on the first date of service, after which time the patient would have been safe to transfer to the floor, given his lower acuity needs. Thus, by the second date of service, ICU-level services were no longer medically necessary. Accordingly, while ICU services provided on the first date of service were medically necessary to treat the patients medical condition, ICU services provided on the second date of service were not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were partially medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in pulmonary disease and critical care 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.