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

A 50-year-old male enrollee has requested lower lumbar spine fusion surgery for treatment of his low back and left lower extremity pain.  Findings:  The physician reviewer found that this patient has chronic back pain. He has chronic knee pain with an abnormal knee exam. He is said to have an L4, L5, and S1 radiculopathy, however there is no evidence present in the records provided to support this diagnosis. The patient is said to have spondylolisthesis and discitis by his orthopedic surgeon, but this has not been confirmed =by any of the other examiners. He is not noted to have spondylolysis, scoliosis, angulation, fracture, -or instability of his lumbar spine which are the accepted criteria for lumbar fusion (Milliman Care Guidelines; Bambakidis, et al). Further, there are no localizing features that would indicate that the L4-5 or the L5-S1 levels are his pain generators. Thus, fusion at L4-5 and L5-S1 is not medically necessary or medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for substance use residential treatment services provided. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Per the records, there was no evidence of suicidality or homicidality, and she was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care.  She was medically and psychiatrically stable to the extent that she did not need 24 hour per day, seven days per week services during the dates of service in dispute. Her medication management and anti-craving medications could have been provided in an ambulatory setting. The patient was motivated and appeared to be working the program. She was cooperative and participating in her treatment plan. She had an extensive period of sobriety with Alcoholics Anonymous involvement. Therefore, she was aware of steps necessary for recovery. Although she continued to struggle with her emotions and required further treatment to help develop coping skills and gain control over her emotional lability/anger, this did not require the structured environment of a residential setting.  This could have been accomplished at intensive outpatient program level of care.  All told, substance use residential treatment services provided were not medically necessary for the treatment of this patient.Final Result: The reviewers 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: Physician reviewer number two 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: Overturned

The patient has requested reimbursement for residential treatment center (RTC) services.  Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level criteria for Clinically Managed High-Intensity Residential Services. The patient was at risk for acute withdrawal, given his continuous long-term alcohol abuse. However, the patient did not require inpatient level of care, given the reported absence of a history of complicated withdrawal. The provider reported that the patient was at serious risk from continued substance use. The provider noted that the patient was at risk of harm to himself or others, given his known agitation and impulsivity. The records documented significant mood instability, which required frequent staff intervention and support. The patients mental status was sufficient to permit participation. The records demonstrated a consistent inability to control his impulses, which placed him at imminent risk of relapse and thus potential for harm to self and others. The patient demonstrated poor insight and limited motivation for change. A structured 24-hour program with therapy and milieu were integral to a long-term positive outcome. The patient was unable to control his substance use disorder without the structure provided by a 3.5 level facility. The patient showed an inability to recognize relapse triggers and lack of insight into his illness. Dimension 6 is met by the records, which state that the patients family and social system included others who participate in substance use. Given these findings, the RTC services were medically necessary for treatment of this patient.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 psychiatry with expertise 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

The patient is a 36-year-old male with a prior history of bipolar disorder. He was admitted to inpatient treatment on 1/18/05 due to decreasing appetite with a 10-pound weight loss, increased irritability, weakness, headaches, and a great deal of oversleeping. The patient estimated the latter at 21 hours a day for about three weeks. Previously, he had been treated with Adderall, which was stopped three weeks prior. More recently he was treated with Lexapro, Trileptal, and Provigil. As of his growing more depressed and irritable, he stopped the Trileptal, but did not notice any difference in his state. Upon admission, he actually denied feeling depressed per se, but did present with the aforementioned history of neurovegetataive change.On 1/19/05, the patient later indicated he was feeling down, sad and guilty that he was unable to work and earn more money. He later indicated to staff that he was very concerned and saddened to have learned that his dog died, feeling it important to return home. He was noted as calm and pleasant on approach. Presented as mildly anxious. On 1/20/05, the patient was noted as quiet and isolative, refusing to attend groups and preferring to spend the day in his room. However, he later indicated that he was going home tomorrow, and was noted as demonstrating brighter affect. His psychiatrist noted him as devoid of suicidal ideation. Finally, on 1/21/05, he was noted as feeling much better and as looking forward to discharge. His medications were maintained as Lexapro 30 mg, amantadine 100 mg, and Trazadone 50 mg, throughout.The patient has requested reimbursement for the acute inpatient psychiatric treatment services he received from 1/19/05 through 1/22/05. The Health Plan has denied this request indicating that the services at issue were not medically necessary.Though the patient warrants ongoing treatment, there is no evidence he warranted treatment at an inpatient level of care as of 1/19/05. Clearly, his response to inpatient treatment in terms of becoming less isolative was fairly brisk and the submitted notes do not demonstrate he was suicidal. Thus, he could have been transferred back to outpatient care as of 1/19/05. 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: Overturned

An 18-year-old female enrollee has requested residential treatment center (RTC) level of care services for treatment of her eating disorder.  Findings:  The physician reviewer found that given the potentially severe and adverse effects of the patients eating disorder behaviors on her medical status (including hypotension and potassium imbalance) pre-mature discharge from the RTC could have placed the patients health in jeopardy. In addition, the patient had recently displayed disordered eating behaviors while on outings from the facility and familial relations were strained resulting in inadequate family support. In light of these factors, transition to a less intensive level of care was not appropriate on the said date. The patient continued to require the intensity of RTC services through the said date. Furthermore, according to letters from the patients treatment team at the time of her discharge from RTC level of care, the patient continues to need intensive intervention due to her overall general malnutrition and history of cardiac problems. Moreover, the patients symptomatic regression so soon after discharge from the RTC reinforces the fragility of this patient and inadequate support system, making re-admission to an RTC level of care medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested chiropractic visits for treatment of her medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient was treated for the same symptoms for a total of 19 office visits.  The treating chiropractors notes do not document an examination in the office notes submitted, and there is no documentation that a re-evaluation was performed.  The records do not include the necessary clinical documentation to warrant additional care, such as range of motion, palpation, and reflexes.  All told, the chiropractic visits at issue were not medically indicated for the treatment of this patient.  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 chiropractic orthopedics 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:An enrollee has requested facial feminization surgeries for treatment of the enrollees gender dysphoria. Based on the entirety of the medical documentation provided for this review, the requested services are not medically necessary and are not reconstructive in nature. The medical literature supports facial feminization surgery which can include forehead remodeling, rhinoplasty, thyroid chondroplasty, and voice alteration procedures for treatment of gender dysphoria. However, the submitted documentation does not support a typical functional deficit in this patients case for each of the requested services. With respect to the patients forehead, hairline and brow treatment, there was insufficient documentation to justify these procedures. A formal examination was not documented. In addition, based on the photographs, the patient has mild forehead prominence and brow ptosis which is consistent with a relatively normal female appearance.  The appearance of the patients forehead and brow is not necessarily gender specific. With respect to the requested lower face/chin and neck procedures, there is a lack of sufficient documentation to support the medical necessity of these services.  A formal examination was not documented - only the procedure request was provided.  In addition, based on the photographs, the patients neck and chin appearance is consistent with a relatively normal appearance and not specifically gender related. With regard to whether the requested services are considered reconstructive in nature, there is a wide spectrum of facial appearance that can be consistent with typical female appearances. In this case, the facial features the patient is seeking to address are consistent with a female appearance and are not considered abnormal. The requested services appear consistent with aesthetic improvement, addressing appearance concerns and not specific sex-related abnormalities.Findings:The physician reviewer found that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheldCredentials/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

This case involves a 51-year-old male who has been treated with chiropractic care for a diagnosis of upper extremity neuropathy and lumbar degeneration. The record over a span of months reveals very little variation in symptom intensity and no resolution of the symptom complex with stability. The patient feels the chiropractic care is helpful and requests additional services. The Health Plan has denied his request based on a determination that the services are not medically necessary.Neither the patient nor the record provided for review conveys which symptoms have improved over the course of the chiropractic treatment.  The clinical evidence does not demonstrate resolution of the initial diagnosis and there are no periods of notable improvement indicated. From an objective prospective, the benefit derived from chiropractic services at this time is not apparent. In the future, should an alternative service be less effective and the patients condition regress, then chiropractic services should be reconsidered.Based upon the information set forth above, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 27-year-old female enrollee has requested Flonase for treatment of her allergic rhinitis. Findings:  The physician reviewer found that the mainstay of treatment for perennial allergic rhinitis includes a nasal steroid. The Health Plans requirement of recent trial and failure of a preferred generic nasal corticosteroid (fluticasone) and a preferred brand nasal corticosteroid (Nasonex) prior to authorization of Flonase is medically appropriate in this clinical situation and consistent with the standard of care. While the patient and her provider indicate that the patient has tried and failed fluticasone, the prior authorization form submitted by the patients provider indicates that the patient has not had a trial of Nasonex in the previous 180 days. Nor is there documentation in the submitted medical records of a trial of Nasonex within this time period. In the absence of objective evidence of unsuccessful treatment with both of the nasal corticosteroids included on the Health Plans formulary list, the medical necessity of Flonase is not established.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee has requested MammaPrint testing for evaluation of the enrollee's breast cancer. Findings:  Two physician reviewers found the requested testing is not likely to be more effective than other methods of evaluation.  MammaPrint testing is a 70-gene assay performed on breast cancer cells.  In negative node patients, it has been validated to be able to place patients in relatively high or low risk categories for distant recurrence and overall survival from breast cancer.  However, the value of MammaPrint testing has not been proven in node positive patients.  Per the submitted records, this patient had two positive nodes.  Therefore, MammaPrint testing is not likely to be of greater benefit than other modalities for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested intravenous antibiotics for more than four weeks for treatment of her medical condition.   Findings:  Three physician reviewers found that this patient has symptoms that do not necessarily represent the diagnosis of Lyme disease.  They are nonspecific, and there is a lack of relevant physical examination findings.  There is no Lyme antibody titer, and other laboratory findings are within normal limits. The diagnosis of late stage Lyme disease has not been established.  There is no synovial fluid for analysis for Lyme arthritis or cerebrospinal fluid positive Lyme titer to support neuroborreliosis.  If the diagnosis of late stage Lyme disease was made, the standard therapy is four weeks of intravenous antibiotic therapy.  Longer courses or repeated courses have not been shown to be efficacious in the treatment of Lyme disease.  All told, intravenous antibiotics for more than four weeks are not likely to be of greater benefit than other treatment options.  Final Result: Three reviewers determined that the requested services are 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:   One reviewer is board certified in internal medicine with sub-specialty certification in infectious disease and is actively practicing.  Two reviewers are board certified in internal medicine 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: Overturned

Nature of Statutory Criteria/Case Summary: A 55-year-old female enrollee has requested reimbursement for the intraoperative radiation therapy. Based on the available documentation, the intraoperative radiation therapy provided to this patient on 5/10/18 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Accelerated partial breast irradiation (APBI) is considered an acceptable standard treatment for patients with early stage breast cancer meeting stringent criteria. These criteria include an age of 45 years or older and a tumor less than 3 cm. Negative surgical margins and negative lymph nodes are also criteria and are confirmed at the time of surgery. For these reasons, the intraoperative radiation therapy was likely to provide this patient with an improved health outcome when compared to standard available treatment options. One reviewer found that the intraoperative radiation therapy was not likely to provide this patient with an improved health outcome when compared to standard available treatment options.Final Result: Two of the three reviewers determined that the services at issue were 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:  One reviewer is board certified in radiation oncology and is actively practicing. One Reviewer is board certified in radiation oncology and is actively practicing.  One Reviewer is board certified in radiation oncology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 32-year-old female enrollee requested authorization and coverage for gastric bypass surgery with duodenal switch.  The health plan has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review.  All three-physician reviewers concluded that the requested surgery is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy.  The health plans denial has been upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 48-year-old male enrollee requested authorization and coverage of IDETfor the treatment of chronic lower back pain.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that IDET is not likely to be more beneficial for treatment of the enrollees chronic lower back pain than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a five-year-old male enrollee has requested for physical therapy for treatment of the enrollees developmental coordination disorder. Findings:  The physician reviewer found that the physical therapy evaluation does not contain the level of detail required to establish the need for additional therapy. The evidence provided does not demonstrate the extent of the patients functional deficits or that he is likely to benefit from additional physical therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A male enrollee has requested reimbursement for the Zoll LifeVest. In this circumstance, there was potential for recovery of left ventricular function over time with medical therapy. Placement of a prophylactic defibrillator is not recommended until at least 90 days have elapsed with continued left ventricular dysfunction demonstrated by an ejection fraction less than 35% despite appropriate treatment. A prophylactic defibrillator before this time has not been demonstrated to improve outcome. Also, studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not been met are largely comprised of registry data without adequate control groups. At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed, or required explantation. For these reasons, the Zoll LifeVest was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the Zoll LifeVest was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were 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:  One reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.