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

A 56-year-old male enrollee has requested 10 treatments of proton beam therapy for treatment of his squamous cell carcinoma of the base of tongue.  Findings:  Two physician reviewers found that the patient has a history of significant radiation dosing to his cervical spinal cord. In light of this, as well as the current C3 vertebral body involvement, it is appropriate to consider this situation as being similar to a spine sarcoma. This patients case should therefore be treated in much the same way as a spine sarcoma. As indicated by DeLaney and colleagues, proton radiation is the standard of care for radiation treatment in patients with spine sarcomas. The authors also note that spine sarcomas are unlike other tumors in that they require doses well in excess of spinal cord tolerance, yet protons have been established to deliver the required doses effectively. Proton beam therapy is likely to provide this patient with a better outcome than Intensity Modulated Radiation Therapy or other standard therapies.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee has requested for Lexapro for treatment of her generalized anxiety disorder. Findings:  The physician reviewer found that Lexapro treatment and has responded positively.A review of the package insert for Paxil (paroxetine) does not indicate that weight gain is a frequent problem. Accordingly, there is no clinical reason to recommend an exception.
Appeal type: Medical Necessity
Decision: Overturned

A 38-year-old female enrollee has requested adult psychiatric acute inpatient hospitalization services for treatment of her behavioral health issues. Findings:  The physician reviewer found that the submitted records note an admission to inpatient service from a partial hospitalization program on the basis that the patient was suicidal. The medical records note that the patient was currently experiencing severe suicidal ideation, severe vegetative symptoms, severe mood disturbance and severe sleep disturbance. The patients history was positive for three prior serious suicide attempts. The patients global assessment of functioning (GAF) was reported to be only 22, which represents severe functional impairment. During treatment, the patient was described as disheveled and feeling hopeless with suicidal ideation. A few days after entering the inpatient hospitalization, the notes describe the patient with severely impaired judgment and indicate that she was also on checks every 15 minutes.  An overall analysis supports a finding of medical necessity for acute inpatient hospitalization of this patient for the dates of service in question, particularly given the patients severe mood disturbance and significant risk for self harm. The placement of this patient at this level of care is also consistent with practice guidelines set forth by the American Psychiatric Association for care of patients with major depressive disorders and suicidal behaviors.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for computerized dynamic posturography, quantitative electroencephalogram, Cambridge Brain Sciences Cognitive Test, and/or videonystagmography. Based on the available documentation, this patient presented to his provider with complaints of vertigo, headache, difficulty falling asleep and tiredness after sustaining head trauma from a water bottle. The patient underwent evaluation with computed tomography (CT) of the head and magnetic resonance imaging (MRI) of the brain, which were interpreted as normal. The patient has symptoms suggestive of post-concussion syndrome. The use of the above the quantitative electroencephalogram and Cambridge Brain Sciences Cognitive Test would not alter the treatment of post-concussion syndrome. The treatment of post-concussion syndrome is supportive, and patients may take years to recover depending on the severity of the injury. As this patient complains of vertigo, computerized dynamic posturography and videonystagmography will be helpful in localizing the cause and likely affect treatment. However, the records do not support an indication for the requested quantitative electroencephalogram and Cambridge Brain Sciences Cognitive Test. Therefore, the requested computerized dynamic posturography and videonystagmography are medically necessary for this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Overturned

The parents of a 14-year-old male enrollee requested authorization and coverage of combination intravenous cidofovir and Alpha Interferon B. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees pulmonary papillomatosis.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. One physician reviewer concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Because two of three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP). Findings: The physician reviewer found that there is sufficient support in the documentation provided for the medical necessity of IOP level of care in this clinical setting. Per the provided documentation, the patient was symptomatic and remains symptomatic. The records through 2018 document this patients mood as depressed, irritable, and anxious.  The patient has been documented as having a lack of motivation and difficulty with attending to activities of daily living. The patient was documented as relapsing on alcohol.  The patient was noted to minimize his relapses as well as other problems related to his substance use. The American Society of Addiction Medication (ASAM) criteria, a set of objective guidelines used by clinicians to assist with treatment planning, advocates for service intensity provided in the least intensive but safe treatment setting. The patients progress with his treatment as well as the progress notes from his treatment providers support IOP level of care. As such, based on current medical literature, ASAM criteria, and the patients documented clinical history, this patients admission to the IOP level of care was and is medically necessary. Final Result: The reviewer has determined that 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 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: Urgent Care
Decision: Upheld

The parent of a 4-year-old male enrollee has requested emergency services for the treatment of the enrollee's medical condition. Findings:  The physician reviewer found that the prudent layperson standard for an emergency requires that the patients condition be of acute onset and of such severity that a prudent layperson would believe his or her health to be in jeopardy without immediate medical attention. The patient in this case had developed a fever and upper respiratory symptoms the day prior. Although he reported neck pain, his neck was described as supple and the patient appeared well, and in no distress. It was noted that he in fact was ambulatory, and walking outside the exam room during his observation period in the emergency department. The patient required only pharyngeal swab testing and oral medication during his visit. The patients symptoms were not acute in onset. While a high fever and neck pain in a three-year-old patient might prompt a parent to seek care from a medical professional, immediate medical attention was not required.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollee risk for breast cancer.  Findings: Two physician reviewers found that there is sufficient support for the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and biopsies and increase in detection of small cancers compared to two-dimensional imaging alone. Although asymptomatic, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.Final Result: Two 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: 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 25-year-old female enrollee has requested for Botox injections for treatment of her migraine headache.   Findings:  Two physician reviewers found that the patient has a diagnosis of migraine, although the frequency and severity are not documented and the effect of prior preventives is not documented. The effect of prior Botox treatment has not been documented by the physician. Although Botox has been shown to be beneficial for preventive management of chronic migraine, the records submitted do not demonstrate that the patient has chronic migraine with failure to respond or intolerable side effects to appropriate conventional preventives. If such records do exist and substantiate a refractory pattern, Botox should be approved for headache prevention.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for radiation therapy services. Findings:  The physician reviewer found that atient is noted to have moderately differentiated estrogen receptor (ER) positive, progesterone receptor (PR) positive, invasive ductal carcinoma with micropapillary features. She underwent treatment with surgery and intraoperative radiation therapy (IORT). The records provided for review support that this patient meets the National Comprehensive Cancer Network (NCCN) guidelines for the use of IORT for the treatment of patients with breast cancer (Daly, et al.). In addition, the patient also meets the American Society of Clinical Oncology (ASCO) criteria for the use of IORT in patients with invasive ductal cancer. Phase 3 studies have shown equivalent outcomes in patients who undergo standard radiation therapy and IORT. The benefits of IORT include reduced visits to the treatment facility, the ability to treat a smaller volume, and fewer toxicities due to a smaller treatment field than with conventional radiation therapy. Given this support, the radiation therapy 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 radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing for the enrollees hyperlipidemia. Findings:  Three physician reviewers found that in this circumstance guidelines for the management of cardiac risk have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of LDL, HDL subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. For example, randomized trials testing treatment with therapy available to reduce homocysteine levels have not shown significant outcomes benefits. Likewise, even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Final Result: Three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers 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: Experimental/Investigational
Decision: Upheld

A 58-year-old female enrollee requested authorization and coverage of a gastric bypass with duodenal switch for the treatment morbid obesity.  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 a gastric bypass with duodenal switch is not likely to be more beneficial for treatment of the enrollees morbid obesity 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested bilateral mastectomy with male chest reconstruction for treatment of the enrollee's gender dysphoria. Findings: The physician reviewer found that the surgical concept of treating breasts for purposes of female-to-male reassignment surgery is well established and documented within the community of plastic surgeons as provided in the references cited above. Each patient must be reviewed on a case-by-case basis to determine medical necessity. In this patients case, medical necessity for the proposed services not been adequately established in the clinical documentation provided. There is suggestion of the presence of female breast anatomy; however, response of the breasts to the testosterone treatment has not been documented and photographs have not been provided to establish that the patient has evidence of continued female breasts. Based on the entirety of the medical record, there is insufficient documentation to support the medical necessity of bilateral mastectomy with male chest reconstruction.With regard to whether the requested services are reconstructive in nature, the submitted documentation does not demonstrate the patients condition constitutes an abnormal structure of the body. The patient is documented to have gender dysphoria and is noted to identify as a male. Thus, adult female breast development would be considered an abnormal male structure. However, the degree of breast development in this patient has not been adequately documented. No photographs were provided for review and the examination detail of the breasts is lacking. Further, the patients response to testosterone has not been adequately documented. As such, it has not been established that the requested services are considered reconstructive in nature.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition or reconstructive in nature. Therefore, the Health Plans denial should be upheld.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

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Two 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 was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested a transcutaneous electrical nerve stimulation (TENS) device for treatment of her urinary incontinence.  Findings:  Three physician reviewers found that a TENS unit is used to deliver electrical stimulation or a current to tissue from cutaneous pads or leads. The device is portable and not implanted. The existing scientific data suggests that TENS can be used for both chronic and acute pain relief, however the indications are controversial. There are only a few reports of TENS in bladder patients and no large, empirical evidence exists to support its utility in this patient population. Further, the contention that the TENS unit may be used to strengthen pelvic floor muscles is without merit as bladder dysfunction is not related to the strength of the pelvic floor sling, rather it is due to intrinsic bladder muscle dysfunction or irritability. Given the lack of studies demonstrating the efficacy of the TENS unit in the treatment of patients with unstable bladder symptoms, its use in the treatment of this patients condition was not likely to produce better results than standard, accepted therapies.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 34-year-old female with facial pain since March 2004. She also has some symptoms of TMJ dysfunction including joint pain and crepitus. She has been treated with a dental occlusal split, orthotics, and anti-inflammatory medication without benefit. Her attending providers have referred her to a tertiary center for further evaluation, diagnosis, and treatment planning. This consultation has been denied by the Health Plan. The requested consultation is medically indicated and reasonable. This patient has facial pain, TMJ pain, and crepitation with an altered chewing pattern. She has undergone conservative therapy without success and her treating providers have recommended the consultation at issue to assist in the evaluation and diagnosis of the patient. Based upon the patients history and lack of improvement, further evaluation is necessary. Therefore, I have determined the requested consultation is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for hyperbaric chamber treatment. Hyperbaric oxygen therapy is indicated for a Wagner 3 or greater diabetic foot ulcer that has failed local wound care and vascular intervention, if appropriate. The records indicate that this patient has local ischemia and a toe ulcer. The patient is not a candidate for surgery or angiography. Confirmation of osteomyelitis or a deep infection was not noted via imaging, biopsy, or cultures. Hyperbaric oxygen therapy is not indicated for isolated vascular disease. Although studies have indicated that hyperbaric oxygen therapy may benefit diabetic foot ulcers not amenable to vascular surgery, skin perfusion results were not provided along with oxygen response to confirm potential benefit from hyperbaric oxygen therapy. In addition, evidence of chronic osteomyelitis refractory to surgery and antibiotics was not demonstrated. For these reasons, the requested hyperbaric chamber treatment is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are 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 family practice with sub-specialty certification in undersea and hyperbaric 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.