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

The parent of a female enrollee requested partial hospitalization program (PHP) eating disorder treatment services for medical treatment of the enrollees eating disorder.  Findings:  The physician reviewer found that this patient appears to have made considerable progress while she has been treated at the PHP level of care. The plan is to fully prepare for the step down of this patient so that even if she has some regression, her overall progress will not be threatened, and she will not need to be readmitted to PHP level of care. Given the information in the record, PHP eating disorder treatment services were and are medically necessary for treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee requested services on an emergent or urgent basis. The physician reviewer found that review of the submitted documentation demonstrates that the patients decision to seek immediate medical attention was consistent with the actions of a prudent layperson. Upon review of the submitted medical records, the patient presented with soft tissue swelling, redness and pain in the right lower eye lid. He was assessed with hordeolum externum and given a prescription for Keflex. In this clinical setting a prudent layperson who was worried that his condition may progress would reasonably believe that the absence of immediate medical attention could result in serious impairment to bodily functions and serious dysfunction of a bodily organ or part. Given that this transpired on a holiday, the patients options for seeking treatment were limited. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would reasonably believe he was suffering from a serious medical condition that required immediate medical attention. Thus, the services meet prudent layperson criteria for emergency care.  Final Result: The reviewer determined the patients symptoms met prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in emergency 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

The parent of a three-year-old male enrollee speech therapy for the treatment of the enrollees delayed speech. Findings:  The physician reviewer found that this patient has speech and language delay that adversely impacts his ability to communicate effectively. In addition to expressive language delay, he exhibits oral motor dysfunction, receptive language delay, auditory comprehension difficulties and articulation deficits. Speech therapy is imperative to treating these issues successfully. Speech and language delay must be taken very seriously in young children because the long-term consequences can be substantial. According to a Cochrane Database meta-analysis of 25 studies, approximately 6% of children have speech and language difficulties. The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment. These reviewers concluded that this meta-analysis showed a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Bernhardt and colleagues concluded that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for at least some children with a history of severe phonological impairment. This patient has delays in multiple areas affecting his ability to communicate successfully. Speech and language therapy is medically indicated to maximize his skills in communication and oral motor functioning.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for Repatha SureClick 140 mg/mL pen injectors. The submitted documentation supports that the requested medication is medically necessary. The patient has established coronary artery disease and mild carotid artery disease in a context that is status post myocardial infarction and left anterior descending coronary artery stenting. The patient has been tried on simvastatin, rosuvastatin, and most recently atorvastatin at a medium/high dose which he could not tolerate owing to both myalgias and memory issues. The patient then self-discontinued this medication due to side effects. Using ezitimibe alone would not be effective in lowering the patients LDL level toward his goal level, given his established coronary artery disease. The patients records include documentation of a recent high LDL cholesterol level. Under these circumstances, the use of a PCSK9 inhibitor is medically reasonable, given the patients established coronary artery disease, his intolerance of multiple statin medications, and his poor control of his LDL cholesterol, which is not near his guideline directed goal. Accordingly, the requested Repatha SureClick 140 mg/mL pen injectors are medically necessary to treat the patients medical condition.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 subspecialty certification in cardiovascular disease, 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

The mother of a 16-year-old female enrollee requested reimbursement for inpatient mental health services the enrollee received from 12/15/01 to 12/20/01. The Health Plan denied the request indicating that the services in question were not medically necessary for treatment of the enrollees medical condition. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the services in question were not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old female enrollee has for a continuous blood glucose monitoring system for treatment of the enrollees type I diabetes.  Findings:  The physician reviewer found that there is documented evidence of over 21 instances of blood glucose levels below 70 mg/dl with some readings as low as 28 mg/dl. The frequency and severity of these episodes require intervention. There is also growing evidence that her control may be improved with the use of the Paradigm Real-Time glucose sensor, as indicated in the referenced literature.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the enrollees breast cancer screening.  Findings: Two physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the presence of implants is not an indication for tomosynthesis. However, the patients breasts that have been described as heterogeneously dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, the breast tomosynthesis was likely to be more beneficial for evaluation of the 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. 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested bronchial thermoplasty for treatment of his medical condition.  Findings: Two physician reviewers found that initial trials of bronchial thermoplasty have demonstrated improved symptom control after the procedure was completed. The AIR trial by Cox and colleagues examined 112 subjects with moderated to severe asthma and demonstrated improved control over the course of the one year follow-up. The RISA study by Pavord and colleagues examined the safety of thermoplasty and found short term worsening in symptoms, but evidence of improved long term control of asthma. Finally, the AIR2 trial by Castro and colleagues compared thermoplasty with a sham procedure and followed the patients out for 12 months as well. The patients in this study had milder asthma when compared with the AIR and RISA study, with far fewer on oral corticosteroids. The study found that the thermoplasty group had fewer exacerbations and improved quality of life when compared to the sham group. Neither the AIR nor RISA trials demographics indicate whether patients were on medications other than steroids (inhaled and/or oral) and bronchodilators. The AIR2 trial on the other hand had 30% of the enrolled patients in the thermoplasty group on other controlling agents and fewer patients on oral corticosteroids. Thus, the data supports the short and long term benefits of bronchial thermoplasty. In this case, bronchial thermoplasty is indicated for this patient. He is on a very aggressive regimen of bronchodilators, is prednisone responsive and is not a candidate for omalizumab as he does not have allergic disease. There is little left in the standard armamentarium to control his described refractory symptoms. Given that all these interventions have not controlled his asthma, bronchial thermoplasty is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: One reviewer is board certified in orthopedic surgery and is actively practicing. Two physician reviewers are board certified in internal medicine with sub-specialty certification in pulmonary disease 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

A 27-year-old female enrollee has requested adult psychiatric acute inpatient services for the treatment of her behavioral health issues. Findings:  The physician reviewer found that the documentation indicates that from the date of service in question forward, the patient was cooperative and stable with no risk of harm to self or others. The providers progress note indicates no withdrawal symptoms and her mood had much improved. Her anxiety and depression were rated a 4 of 10. Based on the level of care utilization system for psychiatric and addiction services (LOCUS), and the American Psychiatric Association (APA) guidelines, this patient would have been a candidate for treatment at a less restrictive level of care than acute inpatient treatment. Since the patient was on a medical detoxification protocol, the services provided before the time period in question were medically necessary. However, the medical records provided do not support the medical necessity for the services provided during the time period in question.
Appeal type: Medical Necessity
Decision: Upheld

A 26-year-old female enrollee has requested authorization for residential treatment services provided for treatment her eating disorder.  Findings:  The nursing and progress notes reflect that the patient was not having symptoms as of a certain date and was doing well. The patient no longer met criteria for continuing stay at a residential treatment level of care as of a certain date.
Appeal type: Medical Necessity
Decision: Upheld

A 65-year-old male enrollee has requested an MRI scan of the knee for an evaluation of his condition. Findings:  The physician reviewer found that there is a lack of documentation justifying the MRI scan. There is no orthopedic exam is available to review in order to justify the MRI scan.  The MRI report describes some vague findings with respect to the menisci.  Grade II signal commonly is associated with myxoid degeneration of the meniscus, and there is no unequivocal description of pathology within the knee which even retrospectively could be construed as findings requiring operative intervention or even more conservative management such as lack of weight bearing.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of diazepam, Adderall, and Ritalin titration therapy for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that Ritalin and Adderall are schedule II medications. These medications are highly controlled and regulated by the U.S. Drug Enforcement and Administration (DEA) and their use require frequent follow up. The records indicate that this patient had not followed up with his provider, which would be eight to nine months from the requested fill date. This length of follow up is not considered standard of care while prescribing schedule II medications. Therefore, it is appropriate and the standard of care for the provider to require face to face follow up prior to continuing schedule II medications. Moreover, switching medications from Ritalin to Adderall without a visit is not considered standard of care. There has been no opportunity to discuss the risks and/or benefits of these medications with his provider. In addition, a mental status examination has not been performed prior to prescribing. It is also not the standard of care to switch from Ritalin to Adderall with only an electronic communication. If the patient is exhibiting behaviors such as frequent early refill requests, it is appropriate to deny these early refill requests. This is also recommended by the DEA. Regarding the patients request for diazepam, the patient has not been prescribed diazepam since June. The patient was also taking a different benzodiazepine (Ambien). It is not the standard of care to combine benzodiazepines. This would have to be discussed at a visit. In this clinical setting, it was appropriate for the provider to deny refilling diazepam, when an evaluation has not been performed for several months. Therefore, Ritalin, Adderall, and diazepam, without appropriate follow up and evaluation, have not been demonstrated as medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined the requested medications 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested peripheral bone mineral density (BMD) testing and breast tomosynthesis for evaluation of her medical condition. Findings: Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Breast tomosynthesis is U.S. Food and Drug Administration (FDA) approved as an adjuvant method of screening along with traditional mammography. In the screening setting, tomosynthesis helps to decrease recall rates by delineating true lesions from spurious lesions caused by overlapping structures seen on routine mammography. Several studies have compared screening by digital mammography alone with the combination of tomosynthesis and digital mammography and found that tomosynthesis increased cancer detection rates, decreased false positives, and decreased call back rates. Most major breast cancers utilized this method for screening patients, especially those with a prior history of breast cancer. Therefore, breast tomosynthesis for this patient was likely to be more beneficial then available standard therapy.  However, the peripheral bone mineral density testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Although BMD measurements at peripheral skeletal sites predict global fracture risk as well as BMD measurement at the hip or spine, the risk for fracture at a particular skeletal site is best estimated by measuring BMD at that skeletal site. The International Society for Clinical Densitometry (ISCD) recommends that the World Health Organization (WHO) criteria be applied to BMD measured by dual-energy x-ray absorptiometry (DXA), using the lowest T-score of the lumbar spine (preferably L1-L4), femoral neck, or total proximal femur. If BMD cannot be measured at either of these skeletal sites due to structural abnormalities, such as osteoarthritis or surgical artifact, then the distal 33 percent (one-third) radius should also be measured and considered for diagnostic classification. In this case, there is no indication in the clinical notes provided for review that the patient required peripheral measurement of her forearm.  Final Result: Two reviewers determined that a portion of the services 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 partially overturned.Credentials/Qualifications: All three physician reviewers are board certified in medical 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vistara Natera genetic testing. Findings:  The physician reviewer found that records provided for review indicate that this patient has undergone Panorama screening, which reported low risk results and Horizon Natera carrier screening, which was negative for 274 out of 274 diseases. A transabdominal ultrasound showed no anomalies and ultrasound consistent with dates. The patients provider has recommended cell-free DNA testing. According to the American College of Obstetricians and Gynecologists (ACOG), cell-free technology may be beneficial to predict the risk for fetal genetic disorders during pregnancy including various skeletal dysplasias, sickle cell disease, and cystic fibrosis. However, there are insufficient data to provide information regarding accuracy and positive and negative predictive value in the general population. Thus, ACOG does not recommend routine use of cell-free DNA screening. Overall, there is a paucity of peer-reviewed medical literature and guidelines supporting cell-free DNA testing as superior to standard testing and evaluation of single gene disorders. Therefore, the requested Vistara Natera genetic testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Vistara Natera genetic testing is not likely to be more beneficial for evaluation 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 evaluation 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 genetics and is actively practicing. Physician reviewer 2 is  board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics and is actively practicing. Physician reviewer 3 is  board certified in pediatrics with subspecialty certifications in genetics and clinical biochemical genetics 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: Experimental/Investigational
Decision: Overturned

A 66-year-old male enrollee has requested robotic prostate surgery for the treatment of his prostate cancer. Findings:  Two physician reviewers found that the procedure of radical prostatectomy can be done through an open incision operation as has been routine for the last several decades. In the last few years, surgeons have learned to remove the prostate with laparoscopy. The addition of robotic assistance has increased the facility, speed, and safety with which this operation can be done. There are now multiple centers with extensive experience doing robotic assisted radical prostatectomy, and the frequency with which it is performed has increased in the last few years. The outcomes for cancer cure and continence appear to be equal to the open procedure. The blood loss and preservation of erectile function are better than open surgery. Postoperative pain and recovery are at least equal to open surgery, and some authors consider it superior. It is therefore no longer reasonable (when more than half of all operations in the country are done this way) to declare it as experimental.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female enrollee requested authorization and coverage of gastric bypass surgery for the treatment of morbid obesity.  The Health Plan denied the enrollees request indicating the requested procedure 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 surgery is medically necessary.