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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 15 therapist hours per week and 10 supervisor hours per month of applied behavioral analysis (ABA) services for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that the request for 15 therapist hours per week and 10 supervisor hours per month of ABA services is not medically necessary for the treatment of the patients medical condition. Numerous scientific organizations have concluded that ABA-based therapies are highly effective in the treatment of autism. However, in this case the Health Plan has authorized a three-month bridging period of ABA therapy with their in-Plan ABA provider. There is a lack of support in the medical records to support the medical necessity for ABA from the out-of-Plan ABA provider. 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 neurology with special qualification in child 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: Upheld

A female enrollee requested eight doses of Perjeta for medical treatment of her breast cancer.   Findings:  Two physician reviewers found that there is a lack of evidence supporting the use of the agent Perjeta in combination with Herceptin, in the adjuvant setting. In the adjuvant setting, the NCCN does not specify the duration of dual-therapy, unlike the recommendation regarding trastuzumab monotherapy where clinical evidence suggests optimal benefit with completion of one year. Accordingly, continuation of Perjeta for an additional eight doses in this patient is not supported by evidence, has not been proven to be safe, and is therefore not likely to be more beneficial for treatment of her medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for Trental and verapamil for treatment of the enrollees Peyronies disease. Findings:  The physician reviewer found that There is a lack of strong evidence based literature to support the medical necessity of the medications at issue in this clinical setting. The use of verapamil injections has been studied for management of patients who are diagnosed with Peyronies disease (PD). However, the literature recommends that further studies need to be conducted to determine its efficacy for the treatment of PD and the associated symptoms with this disease. The American Urological Association Guidelines (AUA) guidelines on PD state that clinicians who consider the use of intralesional verapamil as a treatment option for symptoms of PD should fully consider the weakness of the evidence demonstrating its efficacy. In particular, clinicians should be aware that the lack of control for PDs history in most of the available literature creates substantial uncertainty, particularly given the focus on patients in the acute phase with symptoms that are in a dynamic state. The panel notes that the overall balance between benefits and risks/burdens of intralesional verapamil, therefore, remains unclear given these concerns. The use of greater than 70 treatments with verapamil has not been reported in medical literature. Most trials reported outcomes of once weekly injection for approximately three to six months.  In addition, this patient reported that he does not have trouble with intercourse and his degree of curvature is not documented. As such, the outcome of the therapy in this patients case has not largely been monitored objectively. With respect to Trental, the medical studies are lacking to support its efficacy as a treatment option for patients diagnosed with PD. Hence, the use of Trental is not considered a standard of care for management of patients with PD. For these reasons noted above, Trental and verapamil were not and are not medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested medications were not and 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 urology 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested urgent care services on an emergent basis or urgent basis.  Findings:  The physician reviewer found that upon review of the submitted medical records, the patient presented with a moderate sore throat with the onset a short time prior. Although the patient rated her pain at 9/10, there was also documentation noting 5/10 pain rating. In addition, the patient was not experiencing a fever or difficulty swallowing or breathing. The patient had not taken any medication prior to her arrival at the urgent care center. Her vital signs were normal and the patient was not in any distress. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe she was suffering from a serious medical condition. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services did not meet prudent layperson criteria for emergency care. Further, it has not been established that criteria for urgently needed services were met on the date in dispute. In this case, the patient presented with symptoms of a sore throat that had commenced gradually. The patient did not have a fever or difficulty swallowing or breathing. The patient had not taken any medication prior to her arrival at the urgent care center. In addition, her heart sounds were regular and her lungs were clear. A rapid strep screen was negative for beta hemolytic strep. Based on the documentation submitted for review a prudent layperson in a similar situation would not have believed immediate medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation the patient did not meet prudent layperson criteria for urgently needed services. As such, the Health Plans denial should be upheld.  Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.  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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the IgG test for evaluation of the enrollees medical condition. Findings:  The physician reviewers found that use of food-specific IgG level does not predict true food hypersensitivity, and may actually be a marker of earlier development of food tolerance. Food-specific IgG tests typically yield multiple positive results and may represent a normal immune response to foods. The standard evaluation of food allergy consists of blood IgE level for foods and skin testing. Skin testing for food-specific IgE is used in the diagnosis of IgE-mediated food allergies. For the reasons provided, the IgG test has not been established as likely to be more beneficial for evaluation of the patients medical condition. Final Result: All 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: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in allergy and immunology and 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a duodenal switch procedure.There is a lack of support for the requested services in this clinical setting. Researchers noted, Clinical decision-making should be evidence-based within the context of a chronic diseasewith special attention to nutritional and metabolic issues. In this case, the patient underwent a gastric bypass procedure in 2009 for the treatment of morbid obesity. The patient may be a candidate for revisional or reoperative bariatric surgery. This would require an updated multidisciplinary evaluation documenting her diet, lifestyle and understanding of the potential risks and benefits of a very complex surgical revision. Although conservative efforts at subsequent weight loss are reported in the provider notes note and a pre-bariatric surgery nutrition evaluation was performed on 4/14/21, psychological evaluations were not performed for this procedure. Without this, reoperative bariatric surgery is not recommended. Thus, the requested duodenal switch procedure is not medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested service 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 surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a referral for tertiary neurology services. Findings:  The physician reviewer found that the patient has a history of migraine headaches that have not adequately responded to prior therapies. The patient is currently under the care of a neurologist as reported in the medical records provided for review. The documentation reports the patient is being treated in a manner that is consistent with currently accepted standard of care and practice guidelines from the American Headache Society (AHS). Specifically, the patients current treating provider is addressing her condition using the most recent therapies available including Botox and calcitonin gene-related peptide (CGRP)-based medications. These are the same therapies that are used within tertiary care centers at this time. Given that the patient is receiving care that is consistent with the generally accepted standards of practice, the referral for tertiary neurology services exceeds the patients clinical needs. The referral for a tertiary care evaluation would not be expected to lead to any meaningful improvements in outcome. For these reasons, the requested referral for tertiary neurology services is not supported as 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 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

A 46-year-old female enrollee has requested coverage for epidural steroid injections for treatment of the enrollees low back pain. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested epidural steroid injections in this clinical setting.  This patient has a documented lumbar MRI consistent with her pain.  Additionally, her physical examination is consistent with lumbar radicular pain, including positive straight leg raise and left paraspinal tenderness. The patient has not obtained relief with physical therapy and a home exercise program, and there are valid concerns regarding potential addiction to Vicodin and muscle relaxants.  The current medical literature supports the requested services in this case.  Botwin and colleagues performed a prospective cohort study to identify the therapeutic benefit to fluoroscopically-guided lumbar transforaminal epidural steroid injections in patients with radicular leg pain from degenerative lumbar stenosis.  The authors reported that fluoroscopically-guided transforaminal epidural steroid injections may help reduce unilateral radicular pain and improve standing and walking tolerance in patients with lumbar degenerative disease.  All told, the requested epidural steroid injections are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for surgery (CPT 29914 hip arthroscopy with femoroplasty and CPT 29916 hip arthroscopy with labral repair). This patient presents with ongoing chronic right hip pain with associated swelling, nocturnal pain, and limited range of motion. Significant functional limitations are noted in activities of daily living and ability to work. Clinical examination findings are reportedly consistent with imaging evidence of right gluteus medius with high-grade partial to near complete insertional tear of the greater trochanter and diffuse anterior labral tear. There are documented radiographic findings consistent with femoroacetabular impingement and minimal osteoarthritis, Tonnis grade 1. The provider noted that the patient has failed over six months of comprehensive conservative treatment. Current-evidence based medical literature supports surgical intervention in this patients clinical scenario. In the medical literature, Khan and colleagues concluded that arthroscopic intervention results in improvement in functional outcomes at both the short-term and midterm for patients with symptomatic femoroacetabular impingement in the absence of significant existing degenerative changes. This patients records demonstrate that the patient does not have severe osteoarthritis in the right hip, which could preclude arthroscopic surgery. For these reasons, the requested surgery (CPT 29914 hip arthroscopy with femoroplasty and CPT 29916 hip arthroscopy with labral repair) is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested surgery 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 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: Experimental/Investigational
Decision: Upheld

A 61-year-old male enrollee, with spinal stenosis, has requested authorization for an X-stop decompression procedure.  Findings:  Two physician reviewers found that there is no data demonstrating that X-Stop implantation is superior to traditional decompression in the surgical management of spinal stenosis. Lumbar laminectomy provides more direct and effective decompression and remains the standard of care for surgical treatment of spinal stenosis.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for tilt table testing and referral to a geneticist. Findings:  The physician reviewer found that with regard to genetic testing for Ehlers Danlos, this is not medically necessary. Ehlers Danlos is a rare (1 in 100,000 to 250,000 people) autosomal dominant disease of collagen synthesis. The disease involves skin, viscera, joints, and blood vessels. In this case, there is no family history of Ehlers Danlos reported. The patient has no vascular disease or other typical manifestations of Ehlers Danlos. In addition, the patient has been evaluated by rheumatology and who did not feel the patient to have any rheumatologic disease. In sum, genetic testing is not medically necessary for the evaluation of this patient medical condition. Final Result: The reviewer determined that a portion of the requested services is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and clinical cardiac electrophysiology 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: An enrollee has requested reimbursement for the residential treatment center services provided for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the residential treatment center services were not medically necessary for treatment of the patients behavioral health condition. The patient denied experiencing withdrawal symptoms. The patient was not a danger to himself or to others. He was medically and psychiatrically stable. There were no emotional, behavioral, cognitive, or impulsive symptoms that support the residential treatment center level of care. He had a history of withdrawal seizures, however he was on Keppra and this did not require monitoring at residential treatment center level of care. He was motivated and was working the program. He had a stable support systems in place. The emotional issues that he struggled with in psychotherapy, as well as further development and reinforcement of coping skills, could have been continued at a lower level of care. The structured, 24-hour setting of residential treatment was not medically necessary in this clinical setting. Thus, the services at issue were not medically necessary for treatment of the patients medical condition. 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 with sub-specialty certification 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: Experimental/Investigational
Decision: Upheld

A 47-year-old male enrollee has requested a robotic-assisted laparoscopic partial nephrectomy for treatment of his renal mass. Findings:  Two physician reviewers found that small renal neoplasms as seen in this case can be treated via partial nephrectomy through approaches including non-laparoscopic (conventional surgery), laparoscopic and robotic-assisted laparoscopic techniques. The superiority of robotic-assisted laparoscopic partial techniques has not yet been demonstrated. At this time, there is a lack of outcome data from large, randomized studies demonstrating better results with robotic-assisted laparoscopic partial nephrectomy as compared to standard techniques. Further studies are needed to see if this approach is equal to or better than the other approaches for partial nephrectomy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 56-year-old male enrollee requested authorization and coverage of enrollment in a clinical trial involving treatment with PS-341 and Taxotere. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees metastatic non-small cell lung cancer.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 enrollee's 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 enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for collagen meniscus implant of the right knee for treatment of the enrollees medical condition. Findings:  The physician reviewers found that there is sufficient support for the requested services in this clinical setting.  This patient does not have advanced disease that would require a total knee arthroplasty.  Individuals who have this procedure are improved because their previous quality of life was significantly limited due to advanced arthritis.  For an individual with mild arthritis, however, a total knee arthroplasty would be a poor choice as the kinematics of a knee arthroplasty are poor in relation to a normal knee.  However, although this patient does not have advanced arthritis, he continues to be symptomatic.  He has no history of degenerative meniscal tears that occur through activities of daily living.  Per the medical records, he has had acute meniscal tears due to trauma.  This patient appears to be an appropriate candidate for a cartilage meniscus implant.  In sum, the requested collagen meniscus implant of the right knee is likely to be of greater benefit than other treatment alternatives. Final Result: Two of three 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: Physician reviewers number one, two, and three are board certified in orthopedic surgery and 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.