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

The parents of an 11-year-old female enrollee have requested an OmniPod insulin pump for the treatment of the enrollees type I diabetes. Findings:  The physician reviewer found that the OmniPod is a desirable alternative since there is no tubing to be concerned with. However, the thickness of the disposable pod does lead to it being dislodged upon heavy contact. One limitation of that system is that the lowest basal insulin increments are only 0.050 units/hour versus 0.025 units/hour (provided from other systems). With the OmniPod, the patient has the ability to operate the pump remotely without exposing the pump to others, which can lead to better compliance and control, especially in light of this patients stated concerns. The OmniPod is a reliable pump approved for clinical use by the FDA. Its features are likely to become standard in updated versions of the competitive systems in due course. In summary, an OmniPod pump is medically appropriate and indicated in this case to improve compliance and control.
Appeal type: Experimental/Investigational
Decision: Overturned

A 39-year-old female enrollee has requested intense pulse light therapy for the treatment of her acne. Findings:  Two physician reviewers found that this patient has had cystic scarring acne vulgaris for over twenty years. She has been treated with every medical therapy that is currently available, including Accutane and hormonal therapy. She has required many injections of intralesional steroids to reduce the inflammation of cysts and to prevent scarring. The latter treatments may very likely lead to atrophic scarring if repeated multiple times in the same locations. She has finally achieved good results with intense pulse light therapy for acne. Numerous studies have been published that demonstrate the effectiveness of photodynamic therapy in the treatment of acne vulgaris. Lesion counts are reduced significantly with this therapy. Although it has not been shown to be wholly effective as monotherapy, photodynamic therapy is recommended in combination with topical therapy in patients who do not respond to standard acne treatments or who cannot take systemic retinoids.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee requested authorization and coverage of Synvisc injections. The Health Plan denied the request indicating that the requested injections are not medically necessary for treatment of the enrollees osteoarthritis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested injections are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested hip surgery (surgical release of femoroacetabular impingement syndrome) for treatment of his medical condition.Findings:  Three physician reviewers found that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The services at issue are supported in the peer reviewed literature. The left hip surgery (surgical release of femoroacetabular impingement syndrome) likely avoided and/or delayed total joint replacement. Given the patients age, the alternative total hip arthroplasty would likely require revision arthroplasty. All told, the left hip surgery (surgical release of femoroacetabular impingement syndrome) was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in orthopedic surgery 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

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested partial hospitalization level of care for treatment of her bipolar 1 disorder.  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  This patient remained unstable during the period of treatment in dispute.  She was seen by her psychiatrist multiple times each week, and medication adjustments were frequently required.  In addition, she had complex symptoms of paranoia, hallucinations, suicidal and homicidal thoughts, often toward her family members.  It is also important to note that often she developed these symptoms over the weekends when she was not in the structured environment of the partial hospitalization program.  The current medical evidence supports the services at issue in this clinical setting.  All told, partial hospitalization level of care was medically indicated for the 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 sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an orthopedic referral. This patient presents with a history of chronic right-sided lower rib pain related to exercise. The chest x-ray and chest CT with contrast have revealed an incidental hamartoma of the apex of the lung which has no relationship to this pain. Based on the current literature, the causes related to exercise are diverse and include slipping rib syndrome, which requires a clinical evaluation by an orthopedic surgeon familiar with this condition. The diagnosis of this condition is based on the patients history as well as the hooking maneuver on physical examination. Additionally, pain radiating to the lumbar region and the hip may represent an upper lumbar herniated intervertebral disc. Pain in the lower ribs may also represent a possible stress fracture related to rowing type exercise. All of these conditions necessitate an orthopedic consultation. Given this support, the request orthopedic referral is medically necessary for evaluation and treatment of this patients right-sided rib pain. 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested air and associated ground ambulance transportation services for treatment of the enrollees medical condition. Findings: The physician reviewer found that air and associated ground ambulance transportation services are medically necessary for treatment of the patients medical condition. Based on the documentation submitted for review, a work-up for renal transplantation has been approved at an out of state transplant facility. The patient does not have the option of going to another transplant center. The kidney transplant process takes a great deal of time with referral, wait, appointments, work-up, and approval. The process of getting listed at another center and approved could take up to two years. According to Meier-Kriesche and colleagues, Longer waiting times on dialysis negatively impact on post-transplant graft and patient survival. These data strongly support the hypothesis that patients who reach end-stage renal disease should receive a renal transplant as early as possible in order to enhance their chances of long-term survival. Given that the patient has been approved for transplant and going to a closer facility would be a significant hardship, the requested air and associated ground ambulance transportation services would provide him with the highest standard of care and is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the request 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 internal medicine and nephrology 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: The parent of an enrollee has requested authorization and coverage for once a week allergy injections for 52 weeks (two sets), CPT code 95117 x 16 within a 120-day period and CPT code 95144 x 32 within a 120-day period.  The submitted documentation fails to demonstrate the medical necessity of the requested services. The records do not establish the need for more frequent immunotherapy dosing, According to records, the patients allergy and asthma symptoms were decreased, medications needed were decreased, and quality of life was improved. The records do not document a clinical basis for more frequent dosing. The current medical evidence does not support the requested services in this patients case. Therefore, once a week allergy injections for 52 weeks (two sets), CPT code 95117 x 16 within a 120-day period and CPT code 95144 x 32 within a 120-day period are not medically necessary for the treatment of this patient. 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 pediatrics and allergy and immunology 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 substance abuse subacute detoxification residential treatment center (RTC) services.  Per the American Society of Addiction Medicine (ASAM) criteria, this patient met the criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. The records document that the patient was at high risk of continued substance use, which placed her at serious risk for potential withdrawals and seizures. Given these findings, the substance abuse subacute detoxification 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Jakafi (ruxolitinib)  for treatment of the enrollees graft versus host disease (GVHD). Findings: The physician reviewer found that the requested Jakafi is medically necessary for treatment of the patients medical condition. According to Spoerl and colleagues GVHD is a severe complication of allogeneic hematopoietic cell transplantation (allo-HCT) characterized by the production of high levels of proinflammatory cytokines. Activated Janus kinases (JAKs) are required for T-effector cell responses in different inflammatory diseases, and their blockade could potently reduce acute GVHD. The authors treated six patients with steroid-refractory GVHD with ruxolitinib and concluded that ruxolitinib represents a novel targeted approach in GVHD by suppression of proinflammatory signaling that mediates tissue damage and by promotion of tolerogenic Treg cells. In this case, the patient underwent allogeneic hematopoietic stem cell transplant and developed GVHD. Immunosuppressive therapy is indicated for this patient. There is sufficient medical evidence supporting ruxolitinib has a role in treating patients who have exhausted standard treatment options such as in this case. All told, Jakafi is medically necessary for treatment of the patients GHVD.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and hematology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for a sleep study for evaluation of the enrollee who has a history of epilepsy and encephalitis. Findings:  The physician reviewer found that there is sufficient support in the documentation and in the medical literature for the services at issue in this clinical setting. This patient has been diagnosed with Hashimotos encephalopathy, a poorly understood clinical entity.  However, what is known about this disease complex is that the resultant encephalopathy is associated with sleep abnormalities in over one out of two patients with this treatable syndrome. Since this patient has encephalopathy, with diffuse evidence of brain dysfunction, it is also likely that the reticular activating system is dysfunctional. Thus, a sleep study will help characterize overall brain health and give a correlative index of treatment responsiveness to steroids. Based on these observations alone, a sleep study would have been warranted, regardless of whether there was a clinical history of sleep apnea. Additionally, the records documented a history of sleep disturbance in this patient, which further supported the request for a sleep study. For these reasons, the sleep study performed was medically necessary for the evaluation of this patients medical condition. Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dosage escalation to Humira 40 mg/0.4 mL pens two units every 20 days. Findings:  The physician reviewer found that On review of the current medical literature and the patients records, requested  dose increase of Humira 40 mg two units every 20 days, or one dose every 10 days, is supported as medically necessary for treatment of this patients Crohns disease. Anti-tumor necrosis factor (TNF) medications such as Humira are recommended by the current guidelines for Crohns disease in patients with moderate to severe disease .Treatment with Humira 40 mg more frequently than every 14 days can be supported to prevent disease complications. The remission rate with Humira weekly dosing has been reported at 46.9% versus 22.5% when dosing every other week .In addition, the American College of Gastroenterology (ACG) guidelines state that patients with continued symptoms should have their medication dose adjusted in order to attempt to optimize therapy .In this case, the patient was found to have elevated fecal calprotectin, which is indicative of active disease, as well as a low Humira level, while on Humira 40 mg dosed at every other week.The patients condition stabilized while on his current dose of Humira 40 mg every 10 days. Thus, a decrease in the Humira dose, or a discontinuation of Humira and change to another medication, could result in severe complications of disease activity. Given these findings, the requested dosage escalation to Humira 40 mg/0.4 mL pens two units every 20 days is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested dose escalation is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in gastroenterology 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 53-year-old female enrollee has requested for a panniculectomy for treatment of her excess skin condition and possible hernia. Findings:  The physician reviewer found that there is no loss of functioning member in the record.  There is no abnormal structure or abnormally functioning member due to congenital defects, developmental abnormalities, trauma, infection, tumors or disease. The requested procedures would not be performed to improve function or create a normal appearance to the extent possible.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement for residential treatment center level of care services provided. Findings:  The physician reviewer found that this patient did not meet American Society of Addiction Medicine Criteria for residential level of care.  There was no evidence of suicidality or homicidality.  The patient was medically and psychiatrically stable.   The patient showed mild post-acute withdrawal symptoms at best.  There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with the patient's care. The patient's home environment was sober and the patient's spouse supported necessary efforts. Although the patient continued to struggle with emotions and required further treatment to help develop coping skills and insight, this did not require the structured environment of a residential setting.  The patient could have been stepped down to an ambulatory level of care such as partial hospitalization program. 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 and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for air ambulance transport services provided from California to Texas for treatment of the enrollees status post traumatic brain injury.  Findings:  The physician reviewer found that the air ambulance transport services provided from California to Texas were medically necessary for treatment of the patients medical condition. The patient sustained a severe brain injury with resultant profound functional impairment far from his support network and inpatient rehabilitation facility. Colleagues state that for patients with acquired brain injury different interventions and combinations of interventions are required to meet the needs of patients with different problems. For this patient, inpatient rehabilitation in Texas was approved for treatment of his functional deficits related to traumatic brain injury. Air ambulance was more appropriate than a 30 hour ground ambulance to Texas as it was contraindicated due to placing him out of reach of emergency medical services. Due to his brain injury and medical condition he was not appropriate for commercial air travel. Medical monitoring during air travel was necessary. According to colleagues medical issues related to air travel are relatively frequent. In most cases, they are related to underlying conditions and could have been easily avoided through appropriate intervention. Air travel has health risks, and medical monitoring can minimize health risks during air travel and timely rehabilitation can improve functional outcomes. In sum, to receive specialized rehabilitation with the patients support network, he required transport home by air ambulance. Thus, the air ambulance services provided were medically necessary for treatment of the patients medical condition. Final Result: The reviewers 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: Physician reviewer number one is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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.