Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a coronary artery calcium screen provided by Central Coast Radiology Associates Inc. In this case, the patients ten-year atherosclerotic cardiovascular risk level was intermediate, at five to ten percent, and the records did not document that the patient was on statin therapy for hypercholesterolemia. Under the American Heart Associations guidelines on the management of blood cholesterol, a coronary calcium score of 0 would reclassify the patient as low risk for cardiovascular disease. In this clinical setting, the service at issue assisted the provider in reclassifying the patients risk level and obviated the need for statin therapy. Therefore, the coronary artery calcium screen provided by Central Coast Radiology Associates Inc. was likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the coronary artery calcium screen provided by Central Coast Radiology Associates Inc. at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been 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 internal medicine with sub-specialty certification in cardiovascular disease 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: Overturned

The patient is a 53-year-old woman with long-standing Anorexia Nervosa versus Bulimia Nervosa, as well as Major Depression, recurrent. She has been treated with outpatient therapy and past enrollment in partial hospitalization. Her psychiatrist feels that she has not been making progress in outpatient care. Review of the treatment notes indicates that the patient binges and purges typically 3-4 times per week, sometimes as often as daily, and is often depressed. She has been seen in weekly therapy by her psychiatrist but has continued to binge and purge with regularity. She has been underweight and often reports dizziness as a result.  The patient appears unable to comply with the treatment plan, which included refraining from excessive exercise. Her psychiatrist has referred her back to partial hospitalization. Review of the progress notes from the patients prior course of partial hospitalization treatment points to her having been enormously resistant to not focusing on her body image of being fat, often having trouble eating 100% of the meals, and having relapses of binging and purging. However, she did eventually appear to make some progress, inclusive of weight gain, with the various therapies in addition to treatment with Lexapro and Provigil, with dosages ranging from 10-20 mg and 100-200 mg respectively. By the end of the partial hospitalization program, she was able to more easily, and resist the urge to ingest carbohydrates and then purge them. Treatment notes also mention the patients inclination to cut on herself, something she has evidently done in the past, as well as wanting to leave her psychiatrist of 13 years.  At one point, she brought some of her razor blades with her to one of her outpatient appointments.  The patients provider has recommended a partial hospitalization level of care for the patient. The Health Plan has denied this request on the basis that the requested services are not medically necessary.Given that the patient has clearly not been making progress in weekly outpatient psychotherapy and is still underweight and depressed, it is eminently reasonable to intensify the approach to treatment. As such, only a program with a good deal of daily structure would be expected to be successful and, to this extent, a partial hospitalization level of care is appropriate. Furthermore, review of the patients past course of partial hospitalization indicates she did make some progress. Although the improvement was not sustained over the long term, this would not preclude a return to this level of care. In total, there is sufficient evidence to conclude that partial hospitalization is medically necessary for treatment of the patients medical condition. Accordingly, the Health Plansdenial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for pragmatic speech therapy services for treatment of the enrollees medical condition. Findings:  The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the services at issue. Pragmatic language difficulties are common in children with features of ADHD. The type of therapy required for pragmatic language difficulties is different than speech therapy, as speech therapy does not address language delays or articulation problems. Social communication interventions can be useful for children with pragmatic language impairment. In this case, pragmatic speech therapy is indicated for treatment of the patients diagnosis of social communication disorder.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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics 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 58-year-old female enrollee requested blepharoplasty and ptosis repair for medical treatment of the enrollees bilateral eyelid dermatochalasis and ptosis.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. Visual field obstruction in the absence of eyelid ptosis signifies a problem in the eyeball itself. Visual field obstruction can also be due to some combination of lid position and excess upper eyelid skin hanging over the eyelid margin. In this case, the patients upper eyelid skin is not excessive enough to cause mechanical ptosis as it does not cover the skin below the palpebral crease. Therefore, upper eyelid blepharoplasty is not medically necessary for either upper eyelid.Although the exam documents MRD of 2 mm on the left and 3 mm on the right, the close-up photos show MRDs of about 2 mm bilaterally. The normal MRD is 4 to 5 mm. Therefore some ptosis is present. The surgical options for treating ptosis without excessive skin include frontalis sling or brow suspension, Fasanella-Servat mullerectomy, and levator surgery (resect or repair). The sling suspension is only indicated when the lid is more than 3 mm below in its normal position and the levator function is less than 4 mm. Given that the levator function is not noted it is not possible to know whether levator surgery or sling suspension would be effective. Therefore the documentation submitted for review does not support the medical necessity of a frontalis to upper eyelid fascial sling. All told, based on the medical records submitted for review and the peer-reviewed literature, the requested blepharoplasty and ptosis repair are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for substance abuse residential treatment center services provided for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the substance abuse residential treatment center services provided were not medically necessary for treatment of the patients behavioral health condition. The patient was experiencing mild post-acute withdrawal symptoms. He was not a danger to himself or others. He was medically stable. He endorsed feelings of hopelessness and increased anxiety, however these issues could have been appropriately managed in counseling in an ambulatory setting. He was taking anti-craving medications. There were no emotional, behavioral, or cognitive issues that warranted residential treatment. He was motivated and engaged in his treatment. His family was supportive. In sum, the patient did not require 24-hour monitoring at the residential level of care, and could have safely and effectively been treated at lower level of care. Thus, the services at issue 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for occipital nerve block. Occipital neuralgia is a debilitating pain condition that can be refractory to numerous available treatment modalities. Conservative treatment includes medications and occipital nerve blocks. When conservative options are inadequate, surgical intervention may be indicated. Researchers concluded that, Occipital nerve block as adjunctive therapy has shown safety and efficacy in treating patients with migraines, measured by the reduction in pain. Researchers reported that, Occipital nerve block with a local anaesthetic and corticosteroids provides a safe, simple, and effective treatment method for the patient with medically-refractory occipital neuralgia. In this case, the patient did not experience sustained relief with Medrol Dosepak or Tylenol. Thus, the occipital nerve block was the next appropriate treatment approach for management of this patients occipital neuralgia. Given this support, the occipital nerve block was 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 occipital nerve block was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewer 1 is board certified in physical medicine and rehabilitation with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old female enrollee requested authorization and coverage of Elidel cream. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees eczema.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hypoglossal nerve stimulation with Inspire upper airway stimulation system. The available records document that this patient has obstructive sleep apnea (OSA) that has failed to improve despite treatment with continuous positive airway pressure (CPAP) therapy. The patients provider noted that the patient is not an optimal candidate for oral appliance therapy due to the severity of OSA. There is adequate evidence in the peer-reviewed literature to support the safety, efficacy, and long-term improvement of hypoglossal nerve stimulation with the Inspire procedure in patients with moderate to severe OSA. A meta-analysis demonstrated clinically significant decreases in observed mean apnea/hypopnea index (AHI) and Epworth Sleepiness Scale (ESS) scores, as well as improvements in quality of life scales. The American Academy of Otolaryngology Head and Neck Surgery (AAOHNS) considers upper airway stimulation with the Inspire device via the hypoglossal nerve to be a safe and effective second-line treatment of moderate to severe OSA in patients who are intolerant or unable to achieve benefit with CPAP. For this patient with a body mass index (BMI) of 27.44 kg/m2 and an AHI of 22 events per hour, the Inspire procedure is likely to be more beneficial than CPAP or an oral appliance. Therefore, the requested hypoglossal nerve stimulation with Inspire upper airway stimulation system is 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 hypoglossal nerve stimulation with Inspire upper airway stimulation system is 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 services are 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.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for a consultation with a plastic surgeon. Based on the available documentation, the request for a consultation by a plastic surgeon for an evaluation of this patients complaints is appropriate. The results of the evaluation and subsequent work-up by the provider would determine whether surgical intervention is warranted. The records document new complaints of breast pain and itchiness since her prior evaluation. The evaluation by a plastic surgeon is appropriate, as primary care physicians are not adequately trained in the evaluation of breast implants. All told, the requested consultation with a plastic surgeon is medically necessary for this patient.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 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: Experimental/Investigational
Decision: Overturned

A female enrollee requested BRCA genetic testing for medical evaluation of her medical condition.  Findings:  Two physician reviewers found that the requested testing is likely to be more effective for this patient than other available treatment options. The National Comprehensive Cancer Network (NCCN) guidelines state that testing criteria includes an Individual from a family with a known deleterious BRCA1/BRCA2 mutation. In this case, there is documentation indicating that the patients mother tested BRCA positive. Thus, in this clinical setting BRCA genetic testing is clinically indicated and likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 41-year-old female enrollee has requested an MRI of the right breast for an evaluation of her breast lesion.   Findings:  Two physician reviewers found that a breast MRI is a useful adjunct to mammography and ultrasound to evaluate for multicentric breast cancer. This patient was found to have multiple areas of microcalcifications with architectural distortion highly suspicious for malignancy. In a young patient, it is clinically important to determine the extent of the disease.  Knowing the extent of the breast disease will assist the patient and her physicians in the proper treatment planning for the patients medical condition. Breast MRI has been proven to help determine the extent of the suspected breast cancer. The use of breast MRI also assists in determining the optimal location for biopsy (this patients initial biopsy was negative for breast cancer). The results of this patients breast MRI assisted in the determination of the extent of breast cancer. In my opinion, breast MRI is likely to be more beneficial for the enrollee than any available standard treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a breathing test. While the measurement of fractional exhaled nitric oxide (FENO) is not utilized by itself in the evaluation and management of asthma, it has been demonstrated to be of value in conjunction with clinical parameters. Its use is associated with significantly lower asthma exacerbation rates compared with asthma managed using clinical parameters alone. Further, a recently published review of the literature found that algorithms that include FENO measurements can help in monitoring response to anti-inflammatory, or long-term control medications, including dose titration, weaning, and treatment adherence. In this case, the patient has experienced side effects from various therapies. In order to monitor and treat the patients symptoms, the breathing test was likely to be more beneficial than any available standard testing.Final Result: Two of the three reviewers determined that the service at issue was 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:  One reviewer is board certified in internal medicine with sub-specialty certification in allergy and  immunology and is actively practicing. One reviewer is board certified in internal medicine with sub-specialty certifications in allergy and  immunology and rheumatology and is actively practicing.  One reviewer is board certified in internal medicine with sub-specialty certification in allergy and  immunology 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: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee has requested a follow-up consultation with an allergist for the treatment of her lupus and exposure to mold/mildew. Findings:  The physician reviewer found that there is no clear or close relation between mold exposure and lupus. This patients lupus is very well-controlled on her current regimen, which implies two things. First, there is no evidence that mold exposure has caused any worsening of her condition. Second, she does not have active disease of such severity that she would be at clear risk for opportunistic infection. I agree with the allergists recommendation that the patients concerns fall into the realm of industrial hygiene and occupational medicine.  Given that the patient has already seen the allergist and received his opinion, the fact that she did not like his opinion does not require the Health Plan to authorize further allergy consultation.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer recurrence. Findings: Three physician reviewers found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis is likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure at issue is 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: All three physician reviewers are board certified in diagnostic radiology 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.