Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for services received on multiple dates on the basis that the services were emergent in nature. Findings:  The physician reviewer found that the services at issue were not necessary for treatment of an emergency medical condition. The medical records indicate that the patient had stable orthopedic injuries at the wrist and shoulder. The surgery and associated services could have waited until the patient travelled to an in-plan facility. A sling could have been safely prescribed to manage the injury while the patient was in transit to an in-plan facility. Emergent surgery was not needed. The patient was stable for travel back to California for treatment. Thus, the patient did not receive emergency medical services on the dates of service at issue.Final Result: The reviewer determined the patient did not receive emergency medical services on the multiple dates of service presented. Therefore, the Health Plans denial should be upheld.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

The patient has been diagnosed with bilateral knee osteoarthritis, and is requesting authorization and coverage for Synvisc injections in both knees.Findings: Medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of lasting pain relief from prior viscosupplementation injections. Furthermore, the patients osteoarthritis is not severe enough to warrant a total knee arthroplasty. The patient has tried and failed treatment with ibuprofen and tramadol. The medical evidence supports the requested services in this clinicals setting. Therefore, Synvisc injections in both knees are medically necessary for the 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for an air ambulance transfer from Linden Oaks Behavioral Health-Main Inpatient Campus in Naperville, Illinois, to the Acute Center for Eating Disorders in Denver, Colorado. Medical researchers describe anorexia nervosa as a serious psychiatric disease and that the choice of acute impatient care is driven by the patients severity of symptoms and level of risk. The researchers note that anorexia nervosa is the most severe eating disorder with a protracted course of illness and the highest mortality rate among all psychiatric illnesses. While there are no clear standards regarding ambulance or air ambulance transport for these patients, current medical literature reflects how brittle the medical stability of these patients is. In this case, the patient was medically unstable due to an eating disorder. He had a history of seizure from hyponatremia. The patient was referred by his provider at Linden Oaks Hospital to the Acute Center for Eating Disorders for medical stabilization. While his vital signs remained stable during the air ambulance transfer, the patient became nauseous upon landing and was treated with Zofran. Upon admission to the Acute Center for Eating Disorders, the patient was placed on one-on-one observation for fall risk. In this clinical setting, due to the patients medical instability requiring additional monitoring during transport and the high risk of morbidity and mortality in patients with severe anorexia nervosa, the service at issue was medically indicated. Therefore, the air ambulance transfer from Linden Oaks Behavioral Health-Main Inpatient Campus in Naperville, Illinois, to the Acute Center for Eating Disorders in Denver, Colorado, was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was 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 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 42-year-old female enrollee has requested lesion removal surgery for treatment of her nasal scarring and obstruction.   Findings:  The physician reviewer found that based on review of the available records and photographs, the patient has a scar of the right nose. The scar was caused by previous surgical treatment of the area. Due to a history of bleeding, one could not rule out that this was a skin malignancy. However, there is no documentation that there is a functional deficit with the existing scar. It appears to have matured. There can be functional problems associated with hypertrophic scars (Yang, et al). The existing scar is no longer hypertrophic or immature based on analysis of the photographs. Overall, the patients documentation demonstrates a normal appearance consisting of a well-matured scar that is poorly discernible. All told, the requested surgery is not expected to significantly improve this patients appearance.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for fentanyl patches for treatment of the enrollees chronic pain. Findings:  The physician reviewer found that the physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting opioids. Additionally, when opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to greater than or equal to 50 morphine milligram equivalents (MME) per day, and should avoid increasing dosage to greater than or equal to 90 MME per day or carefully justify a decision to titrate dosage to greater than or equal to 90 MME per day.  In this case, the patient has requested per day. No medical evidence-based rationale is given for this high of a dosage. Dose escalation is not a long-term plan, but a short-term plan for the treatment of tolerance. The records indicate that tolerance has taken place since the start of the narcotics. In this case, there is the possibility of opioid-induced hyperalgesia. No clear objective goals with this high of a dose of opioid have been established, and other non-pharmacological treatments have not been exhausted or even addressed. There is no documentation of behavior therapy despite significant research to support its use. All non-opioid medications classes have not been exhausted. The current medical evidence does not support the requested medication in this patients case. Therefore, fentanyl patches are not medically necessary 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 anesthesiology with sub-specialty certification in pain 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

A 19-year-old male enrollee has requested reimbursement for inpatient treatment services for treatment of the enrollees depressive disorder.  Findings:  The physician reviewer found that inpatient psychiatric care is aimed at decompressing the acute exacerbations of serious psychiatric symptomatologies. In the case of this patient, he was a distressed adolescent at risk of not only harming his father, but harming himself as well when one considers his past history and medical condition (Brent, et al.). The submitted documentation clearly demonstrates that this high-risk case represented a psychiatric emergency. There is no available data supporting a consistent length of inpatient hospitalization in cases such as this. In such cases, physician-led, multidisciplinary teams are tasked with performing serial, systematic evaluations throughout a hospitalization to determine the necessity of continued inpatient care.  On-going evaluation, combined with effective therapies, family involvement, case management services and discharge planning constitutes at least part of the duties of an inpatient staff.  It appears the staff worked these issues diligently and logically during the admission with the goal of a seamless transition back to the community, with a mitigated risk for readmission. The decision regarding a patients level of care should depend primarily on the patients level of function and safety to self and others, as determined by the severity of depression, presence of suicidal and/or homicidal symptoms, psychosis, substance dependence, agitation, childs and parents adherence to treatment, parental psychopathology and family environment (Birmaher, et al.).  In this patients case, discharge on the first day that care was provided would have been premature. That day, the attending psychiatrist described the patient as depressed, with persistent homicidal ideation who was angry, isolative, withdrawn, and tearful. Two days later, the physician documented that the patient remained homicidal and depressed with poor activities of daily living, mood lability and continued self-isolation. The note from the fifth day in treatment describes a much-improved patient ready for discharge the following day.  All told, this was an appropriate admission of a high-risk patient. The services at issue were consistent with standards of good medical practice in the psychiatric community and were medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested authorization and coverage for proton beam radiation therapy. The records provided for review demonstrate that this patient presents with a history of meningioma with recurrence over the right optic nerve. The use of proton radiation for treatment of this patients meningioma is not supported as superior per the current peer-reviewed medical literature. The standard of care in this clinical setting remains photon-based radiation therapy. A course of photon-based intensity modulated radiation therapy (IMRT) would provide this patient with acceptable risk to the surrounding normal critical structures. Although proton radiation has the ability to reduce low dose exposure to surrounding normal critical neuroendocrine structures, this low dose sparing has not been correlated with an improvement in clinical outcomes. Additionally, some studies report excessive toxicity with the use of proton beam radiation (Vaphiades). All told, the requested proton beam radiation therapy is not 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 that the requested proton beam radiation therapy 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 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: Physician reviewers 1, 2, and 3 are board certified in radiation oncology 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 20-year-old female who sought correction of her developmental and congenital chest wall deformities at a breast care center. Her evaluation revealed a combined congenital anomaly (pectus excavatum) and developmental defect (tubular breasts) that has resulted in medially displaced breasts that are asymmetric and tubular. The patients provider recommended bilateral placement of breast implants and repair of the tubular breast deformity on the right side. The Health Plan has denied authorization for the requested procedure on the basis that it is cosmetic in nature.The description of the defects by the patients surgeons as well as the accompanying photographs demonstrate the complexity of the patients condition. This patient has both congenital and developmental abnormalities, which have resulted in an abnormal structure of the body. Thus, the requested procedure constitutes a reconstructive procedure under California law. Though it will be difficult to achieve symmetry and the breasts are likely to remain medially displaced due to the pectal defect, the requested procedure is medically justified. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

enrollee has requested authorization and coverage for removal of three moles. This patient has abnormally enlarged moles which are documented to be painful.  Thus, removal to accurately diagnose the melanocytic nevi and to treat the functional impairment of pain is medically necessary. This patients condition constitutes an abnormal structure of the body. The records document enlarged, painful nevi, which are considered to be an abnormal structure. This condition is consistent with skin tumors/neoplasm. The requested services are likely to both improve function and create a relatively normal appearance to the extent possible. Based on the documentation submitted for review, the requested services are likely to provide more than a minimal improvement in the appearance of this patient. In sum, the requested removal of three moles is medically necessary and is reconstructive in nature.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested intravenous antibiotic therapy for treatment of her medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Outpatient therapy of diabetic foot infections is provided via the oral or intravenous route.  Intravenous therapy is preferred in cases in which there is significant infection and potential risk for amputation.  Generally, this therapy is provided on an outpatient basis unless the patient has very significant comorbid disease, such as severe cardiac or pulmonary disease, or is septic.  In this case, the documentation indicates that the patient refused a PICC line.  However, there is no clinical documentation indicating that the patient was at high-risk for a PICC line associated infection.  Additionally, PICC lines are used on a regular basis in patients at high-risk for infection.  All told, hospitalization from the time period specified for completion of intravenous antibiotic therapy was not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for Inlyta (axitinib). While there is a lack of evidence from strict randomized clinical trial evidence due to the rarity of soft tissue sarcomas, phase 2 clinical trials have shown promise regarding the use of axitinib and pembrolizumab. Wilky and colleagues report in single-center, single-arm, phase 2 trial of 33 patients with histologically confirmed advanced or metastatic sarcomas, including alveolar soft-part sarcoma, axitinib plus pembrolizumab had manageable toxicity and that preliminary activity in patients with advanced sarcomas warranted further investigation in randomized controlled trials. The National Comprehensive Cancer Network (NCCN) guidelines specifically mention the use of pembrolizumab in the treatment of certain soft tissue sarcoma such as undifferentiated pleomorphic sarcoma. In this case, the patient has a diagnosis of advanced undifferentiated pleomorphic sarcoma. The patient has exhausted standard therapies and the provider has recommended treatment with a combination of pembrolizumab and axitinib. Therefore, Inlyta (axitinib) is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Inlyta (axitinib) 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 medication is 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 reviewers 1 and 3 are board certified in internal medicine with sub-specialty certifications in medical oncology and hematology and are actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certification in medical oncology 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

The enrollee is requesting authorization and coverage for an injection of Monovisc for the right knee. The enrollee has a history of three prior arthroscopic knee surgeries due to meniscal injuries. He had been doing well until he fractured his left ankle. He was provided a brace for the left ankle. His right knee developed pain with prolonged sitting on the bus and with walking. His knee has started to improve.  He is favoring his left ankle less because he is now in an ankle sleeve. The pain is primarily around the knee cap. Previous treatments include ibuprofen, ice, and activity modification. The enrollee was referred to physical therapy. The physician diagnosed the enrollee with moderate osteoarthritis of the knee. His physician is requesting Monovisc. A recently published scientific statement presents high-level care recommendations for the general use of hyaluronic acid injections, but the statement does not provide guidance for specific clinical scenarios. A multidisciplinary panel of health care providers, with substantive knowledge of intra-articular hyaluronic acid injection therapy, formed a workgroup to investigate the appropriate use of hyaluronic acid injections in patients with knee osteoarthritis. This workgroup developed appropriate use criteria for hyaluronic acid injections. The benefit of these injections in individuals with mechanical meniscus pathology, with underlying osteoarthritis of the knee was considered uncertain by the workgroup. This enrollee has moderate arthritis. The medical literature describes exercise-based therapy as the foundation for treating knee osteoarthritis. This enrollee has not completed a recent course of physical therapy. Physical therapy was prescribed at the same time as viscosupplementation. The authors indicate weight loss should be encouraged for all patients with osteoarthritis and a body mass index greater than 25 kilograms per square meter. The enrollee has a body mass index of 34. Medical records indicate weight loss was recommended by the provider. Corticosteroid injections are effective for short-term pain relief in patients with osteoarthritis. A trial of conservative care is typically recommended prior to treatment with hyaluronic acid (Monovisc) and medical records do not support a trial and failure of conservative care in this case. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 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 enrollee's risk for breast cancer. Findings: Two physician reviewers found that there are sufficient supports 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 biopsies and callbacks and increase in detection of small cancers compared to two-dimensional imaging alone. Although the patient was asymptomatic, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had the 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.