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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for referral to a dermatologist.The U.S. Preventive Services Task Force (USPSTF) has concluded that the current evidence is insufficient and that the balance of benefit and harms of visual skin examination by a clinician to screen for skin cancer in asymptomatic adults cannot be determined. Memorial Sloan Kettering, a prominent melanoma treatment center, also does not recommend routine skin cancer screening. Researchers performed an updated systematic review for the US Preventive Services Task Force regarding clinical skin cancer screening among adults. They concluded that limited evidence was identified for skin cancer screening, particularly regarding potential benefit of skin cancer screening on melanoma mortality. In this case, the patient does not have a personal or family history of skin cancer, and he does not have any reported symptomatic lesions. In addition, records reflect that the patient was evaluated by his primary care physician, and the progress note for this appointment states that the patients skin revealed no rashes or lesions. It would be within the scope of practice of the primary care physician to screen the patients skin and make appropriate referrals if necessary. Under these circumstances, the requested referral to a dermatologist is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in dermatology 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:  The enrollee requested coverage for Proton Beam Radiation Therapy for a diagnosis of malignant neoplasm of the connective and soft tissue with history of Hodgkins lymphoma that were treated with chemotherapy and radiation. The enrollee developed synovial sarcoma in the mediastinum and had a resection and then developed metastatic disease with a recurrence in the abdomen. He underwent proton beam radiation therapy.  The enrollees Radiation Oncologist indicates the tumor is located in very close proximity to many critical organs  the heart, lungs, esophagus, spinal cord, liver, and bowels. As a result, in order to deliver adequate radiation to this location, proton therapy was recommended. It is noted that with an absence of exit radiation, proton beams can deliver radiation to target in close proximity to critical structures while minimizing the risks of acute and late toxicity. Two of the three reviewers determined that according to the medical literature, proton beam radiation therapy is indicated, specifically in this case, due to previous radiation received in treatment. The literature indicated proton beam therapy would deliver a lower dose to spare critical structures. One reviewer determined the proton radiation did not offer a significant advantage over the standard treatment. Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Therefore, the health plans denial is overturned.Credentials/Qualifications: Three reviewers are board certified in Radiation Oncology 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: Overturned

An 18-year-old female enrollee has requested coverage for inpatient psychiatric hospitalization level of care from a specific date and forward for treatment of the enrollees depression, anorexia nervosa, and malnutrition.  Findings:  The physician reviewer found that based on review of the available records, this patient presents with symptoms consistent with severe anorexia nervosa. In this case, the patient has a markedly disordered body image and does not have the motivation to get well. She is chronically depressed and has expressed a desire to kill herself by starvation. Her weight is 86% of her IBW, but she continues to have tachycardia upon standing. Overall, the patient does not seem to have developed the insight or the motivation to succeed in a less restrictive treatment environment. She feels that the required amount of food she is given is making her fat and sick. She also overestimates the amount of food she has eaten, stating she has eaten 100%, when the providers indicate that she may have barely eaten 50%. She has not progressed in the amount of food she has eaten during this admission. She also indicates that she has gained a considerable amount of weight, when the records document that she has not gained any weight. The American Psychiatric Association (APA) treatment guidelines state that it is important to consider a patients overall clinical and social picture rather than simply rely on weight criteria. Further, the APA notes that weight level per se should never be used as the sole criterion for discharge from inpatient care. Patients need to both gain healthy body weight and learn to maintain that weight prior to discharge. It is clear from the records that this patient has not learned to maintain her weight and is actively fighting the staff when they work to help her gain the weight in the first place. This patient is not ready for discharge and would quickly relapse in a lower level of care. For these reasons, continued inpatient level of care is supported as medically necessary from the date in question and forward.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar microdiscectomy for treatment of the enrollees low back pain. Findings:  The physician reviewer found that the submitted documentation supports the requested services in this clinical setting. This patient presents with persistent low back pain radiating into the left lower extremity to the calf, with numbness and tingling localized to the plantar foot. His symptoms were aggravated by sitting, standing, walking, and bending. His symptoms interfered with activities of daily living. Clinical examination findings evidenced sensory deficits and reflex changes consistent with imaging evidence of L3-L4 and L4-L5 disc protrusions with nerve root compromise. Selective nerve root blocks at left L4 and L5 provided temporary symptom relief. He had failed to improve despite long-term non-operative treatment, including medications, physical therapy, chiropractic care, activity modification, and injections. The medical evidence supports the requested services in this clinical setting. 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 orthopedic 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: Overturned

A 49-year-old female enrollee requested authorization and coverage of reduction mammoplasty for the treatment of chronic intertrigeneral dematosis as well as occasional pyoderma and cyst formation. The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested procedure is medically necessary for treatment of the patients medical condition.
Appeal type: Urgent Care
Decision: Upheld

A 56-year-old female enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that the patient went to the ED at the direction of her primary care physician for complaint of sore throat and cough of several days duration. She was having no difficulty breathing, and her vital signs were normal. At no time during her visit did her condition deteriorate to an unstable condition. Her vital signs remained normal. Her condition could have been safely treated in a physicians office. There is insufficient documentation in the medical record to support the necessity of a visit to the ED.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Latuda for treatment of her behavioral health conditions. Findings:  The physician reviewer found that Lurasidone is an atypical, or second generation, antipsychotic medication initially approved for the treatment of schizophrenia.  In mid-2013, Latuda gained two additional indications, both for the treatment of bipolar illness.  There have been several studies demonstrating the clinical benefit of atypical antipsychotics in treating unilateral depression.  The data at this point best supports aripiprazole and quetiapine, followed by risperidone and olanzapine.  At this time, the peer-reviewed medical literature does not support Latuda as a first-line pharmacological treatment intervention for major depressive disorder.  Considering that the record does not demonstrate treatment failure of well-established augmentative strategies, such as buspirone, aripiprazole, quetiapine, olanzapine-fluoxetine, lithium or thyroid hormone, while the status of non-pharmacologic interventions such as an evidence-based psychotherapy for major depressive disorder is unclear, the medical necessity of the requested medication has not been established.  Therefore, the requested medication Latuda is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xifaxan tablet 550 mg three times a day, indefinitely. The records provided for review document that this patient has a history of constipation. The patients provider has recommended ongoing treatment with Xifaxan. Xifaxan has been demonstrated to be safe and effective for the treatment of patients with irritable bowel syndrome-diarrhea predominant (IBS-D). Additionally, Xifaxan has been found to be effective for the treatment of patients with small intestinal bacterial overgrowth (SIBO). However, there is concern for the development of resistance to Xifaxan with long-term use. In this case, there is a lack of submitted documentation of IBS-D or SIBO to support an indication for treatment with Xifaxan. Moreover, there is a paucity of data in the peer-reviewed medical literature or current guidelines to support to use Xifaxan for an indefinite duration. For these reasons, the requested Xifaxan tablet 550 mg three times a day, indefinitely, is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the requested Xifaxan tablet 550 mg three times a day, indefinitely, is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in gastroenterology 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: Upheld

A 44-year-old female enrollee has requested for cognitive rehabilitation therapy for treatment of her primary sleep disorder and post traumatic stress disorder (PTSD).    Findings:  The physician reviewer found that neurofeedback is not currently within standards of good medical practice for the treatment of anxiety, PTSD or sleep disorders within the organized medical community. The current practice guidelines for anxiety, PTSD or sleep disorders do not include neurofeedback (see NIH and VA/DoD guidelines cited above). The references submitted with this appeal are not sufficient to demonstrate the efficacy of neurofeedback in this setting.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for L5-S1 lumbar laminectomy with S1 fusion. A review of the literature includes moderate evidence of good outcomes from standalone lumbar fusions for chronic pain with or without instability. In this case, the records document a history of chronic low back pain with right more than left sciatic pain. There is a history of paresthesias and intermittent numbness in the lower extremities. There is evidence of disc-osteophyte complexes bilaterally at L5-S1 on magnetic resonance imaging (MRI). Epidural steroid injections at L5-S1 have been effective in relieving the right-sided radicular pain on a temporary basis indicating the presence of neurocompression on the right side. The patient has tried and exhausted conservative treatment. The current medical literature reveals that fusion in addition to laminectomy results in greater success than discectomy alone in the lumbar spine. Therefore, the requested L5-S1 lumbar laminectomy with S1 fusion is medically necessary for treatment of 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 orthopedic 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

A 63-year-old female enrollee requested Harvoni 90mg-400mg for medical treatment of her hepatitis C. Findings:  Two physician reviewers found that in this patients case, the requested medication is not medically necessary.  The medical records do not include the results of a recent liver biopsy or non-invasive testing to determine the severity of her fibrosis.  She has no mentioned systemic manifestations of hepatitis C, such as cryoglobulinemia or leukocytoclastic vasculitis.  There is a lack of support for the requested medication in this clinical setting.  All told, the requested Harvoni 90mg-400mg is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla (apremilast) for treatment of the enrollees psoriatic arthritis. Findings: The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The records demonstrate the patients joint disease is active and is peripheral. Treatment recommendations for peripheral arthritis include non-steroidal anti-inflammatory drugs (NSAIDs), intra-articular glucocorticoid injections, disease-modifying antirheumatic drugs (DMARDs) and [tumor necrosis factor] TNF inhibitors (Ritchlin, et al). Anti-TNF agents have been proven effective for psoriatic arthritis and are disease modifying agents. Anti-TNF agents prevent progression of disease, erosions and disability and are the preferred agent for psoriatic arthritis (Gossec, et al). Otezla is an orally administered phosphodiesterase-4 inhibitor available for the treatment of psoriatic arthritis but it is not currently known to be disease modifying. As such, it is not a preferred agent for the treatment of psoriatic arthritis (Gossec, et al) In this case, the patient has failed one anti-TNF agent and the medical records fail to demonstrate that the patient has a contraindication to a trial of a second preferred anti-TNF agent. As such, the request for Otezla has not been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested intravenous immune globulin (IVIG) therapy for treatment of the enrollees relapsing remitting multiple sclerosis. Findings: Three physician reviewers found that this patient has relapsing multiple sclerosis and is requesting IVIG therapy for ongoing treatment, not for a relapse, but rather as a disease modifying therapy. While the records document the patient has been treated with interferon and Tecfidera, there are standard U.S. Food and Drug Administration (FDA) approved agents available for multiple sclerosis including Gilenya, Lemtrada, and Tysabri. IVIG is not an FDA approved therapy for the treatment of multiple sclerosis. While there have been many small trials, the results are mixed, and IVIG is not typically included in the options used to treat relapsing multiple sclerosis except for a severe disabling exacerbation not responding to intravenous steroids. At this time, there is a lack of evidence that IVIG is more effective as a disease modifying agent than any of the standard therapies. For these reasons, the requested IVIG is not more likely to be effective for the treatment of this patient than other standard therapies.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: All three physician reviewers board certified in neurology 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 parent of a two-year, seven-month-old male enrollee has requested physical therapy for treatment of the enrollees developmental delay.  Findings:  The physician reviewer found that this patient has MRI evidence and clinical findings of an identified neonatal stroke. Perinatal ischemic stroke is a well-recognized cause of neurologic morbidity in children, leading to cerebral palsy, epilepsy, and cognitive deficits (Raju, et al). Overall, there is a growing recognition of the importance of motor activity for the development and maintenance of central nervous system pathways and for recovery of function post injury (Martin, et al). With regard to treatment, Husson and colleagues concluded that early intervention helps alleviate these disabilities. In addition, Damiano reported that PT has a prominent role in stimulating neuroplastic changes in damaged developing nervous system. This patients history of neonatal stroke with resulting seizures provides evidence that this is a medical condition. Given that this patient exhibits greater than 50% delays in gross motor skills and PT is recommended for patients with any delays greater than 33% the requested PT services have been established as medically necessary for treatment of his condition.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested a magnetic resonance imaging (MRI) (left knee) and an orthopedic consultation for evaluation of the enrollees left knee pain. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. It is reasonable for patients to have further follow-up that would include an orthopedic referral and MRI with documentation of swelling, catching, locking and positive clinical signs suggesting internal derangement of the knee. However, in this patients case there is no documentation indicating instability or locked knee. In addition, the x-ray examinations were noted to be negative. Moreover, the submitted documentation does not demonstrate exhaustion of conservative treatment. Thus, a thorough trial of conservative management is reasonable and appropriate in this clinical setting. Based on the medical literature cited above and the documentation submitted for review, the requested services are not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 70-year-old male enrollee has requested chiropractic care for treatment of his history of compression fracture of the spine.  Findings:  The physician reviewer found that based on review of the available records, the requested chiropractic care is medically necessary for treatment of this patients medical condition. According to the records, chiropractic treatment has been the only modality to provide him with decreased pain and increased function. Even though this patient has a history of a lumbar compression fracture, this condition is not new and was diagnosed in 2011. An old fracture that has healed is not considered a contraindication to chiropractic care (Rubinstein, et al). A chiropractor should be able to better determine whether a subluxation is present. Given these facts, the requested chiropractic evaluation is supported as medically necessary and should be provided to this patient.