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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the left knee. The American College of Radiology (ACR) criteria state that MRI is indicated for non-traumatic knee pain when pain is persistent, and radiographs are non-diagnostic. However, MRI is not recommended before a thorough physical examination and radiography, or for severe degenerative joint disease, inflammatory arthritis, stress fracture, osteonecrosis, or chronic regional pain syndrome. Researchers concluded that the management of patients with knee pain for degenerative meniscal tears and degenerative joint disease in its initial stages remains nonoperative. Currently, MRI has not been shown to add substantial value in the management of patients with degenerative disease. Failure to respond to nonoperative measures warrants orthopedic assessment with radiographic studies and counselling on managing degenerative joint disease. This patient is being treated for left knee pain. The patients left knee pain has been worsening recently and is interfering with his ability to sleep. He presented to the emergency department and x-rays showed no visible acute osseous injury, with evidence of tiny patellofemoral osteophytes. The patient underwent treatment with a cortisone injection and medications. On 10/6/21, he presented with continued severe pain rated at 9/10 with clicking and popping. Physical examination findings demonstrated slight trace of effusion and medial joint line tenderness. There is a lack of documentation of any formal physical therapy or completion of physician-directed exercises to support an indication for MRI of the left knee. For these reasons, the requested MRI of the left knee is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. 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 is an 18-year-old male with chronic inflammatory demylinating polyneuropathy (CIDP). Previous treatment with IVIG has been beneficial for his condition. The patient is seeking further treatment with IVIG. The Health Plan has denied this request because there is a shortage of IVIG and the Health Plan is reserving IVIG for patients with life-threatening illnesses. The patient did not tolerate treatment with plasmapheresis. IVIG is a valid and accepted treatment for CIDP. This patient has responded positively to IVIG. The information provided demonstrates IVIG is the indicated therapy for this patient. Furthermore, records provided demonstrate plasmapheresis is not indicated for this patient. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients CIDP. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A sixty-one year-old female who developed new headaches, episodic tingling, unsteady gait, and lightheadedness is requesting coverage for auditory evoked potentials testing (BAER test).  Reviewers Findings:  The reviewing physician found that the BAER test is clinically useful when looking for subclinical lesions to assist in diagnosis of multiple sclerosis (MS), and as a screening test for schwannoma of the eighth nerve. The BAER test is occasionally helpful in identifying a central site for vertigo. In this case, the clinical notes do not suggest this patient has vertigo, hearing loss or MS.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 38-year-old male enrollee has requested acute inpatient psychiatric services for treatment of his bipolar disorder and polysubstance dependence. Findings:  The physician reviewer found that the patient was quite encumbered by his mood symptoms and his medication management was complex. It appears the patient's anxiety and agitation only settled somewhat towards the very end of the inpatient period. All things considered, the patient clearly warranted all the inpatient treatment he received.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zelboraf (vemurafenib). Findings:  The physician reviewer found that The request for Zelboraf is medically necessary for treatment of the patients medical condition. BRAF is an important signal transduction protein that signals within the same pathway as KRAS and EGFR, which are frequently overexpressed or mutated in colon cancer. Zelboraf is a specific inhibitor active against the BRAF V600E mutant protein that was present in this patient. Although there was not much single agent activity in phase II studies, the studies did show efficacy when combined with chemotherapy . A study of 86 patients where the progression-free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. This trial has significant results for patients with stage IV tumors. As such, results from molecular profiling offers a rational selection of the next regimen. For the reasons provided, treatment with Zelboraf has been established as medically necessary for treatment of 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 sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for inpatient eating disorder hospitalization services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee who has a history of eating disorder.Findings: The documentation submitted supports the medical necessity for the services at issue in this patients case. The patient remained focused on losing weight and the number of calories she consumed. The patient struggled with meal compliance. Her weight was documented as 81.6 pounds with a body mass index of 16.7. The American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for youth (AACAP, 2014). The CASII utilizes dimensions that are relevant to the youths clinical status when determining appropriate level of service intensity. These dimensions include risk of harm, functional status, co-occurrence, environmental stress, environmental support, resiliency and/or response to services, child/adolescent involvement in services, and parent involvement in services. Based on this patients clinical history provided and the documentation as outlined above, on 2/20/18 through 2/28/18, the patient met CASII criteria for level 6 secure 24 hour services with psychiatric management. The patients clinical status, in addition to current medical literature, support that the treatment at the inpatient level of care from 2/20/18 through 2/28/18 was medically necessary for this patient (American Academy of Child and Adolescent Psychiatry CASII; Hergenroeder et al; Morris et al).  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: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi and Daklinza for treatment of her hepatitis C virus infection.  Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi, PEG-interferon, and ribavirin for 12 weeks. This is based on the Boson trial, which showed cure rate of 95% in treatment-naive genotype 3 patients (Foster, et al).  The AASLD/IDSA guidelines specify contraindications to interferon in the following circumstances: hemoglobin below 10 g/dL, platelet count below 90 K/uL, decompensated cirrhosis, autoimmune hepatitis, uncontrolled depression, or existing cardiac disease. The Food and Drug Administration (FDA) approved prescribing information for PEG-interferon lists only decompensated cirrhosis, known allergy to PEG-interferon, and autoimmune hepatitis as contraindications. None of these are substantiated in the provided records. For these reasons, although treatment of hepatitis C is warranted in this case, there is no literature to support an exception for the use of Sovaldi and Daklinza for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty 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

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested in-home therapy service for behavior modification with a psychotherapist for treatment of the enrollees behavioral health condition.  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. According to Antshel Although stimulant medications represent an evidence-based approach to managing ADHD, psychosocial interventions for child/adolescent ADHD target functional impairments as the intervention goal, and rely heavily on behavioral therapy techniques and operant conditioning principles. Evidence-based psychosocial interventions for managing pediatric ADHD include behavioral parent training, school-based interventions relying on behavioral modification, teaching skills, and operant conditioning principles, and intensive summer treatment programs. Behavior treatment includes both social and psychological therapies and often involves medical, educational, and behavioral treatments used together. In this case, the medical necessity for in-home therapy service for behavior modification with a psychotherapist has not been established for treatment of the 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 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 fifty-seven year-old male with a history of with post laminectomy syndrome is requesting authorization and coverage for Lyrica.  The patient is currently taking low doses of Neurontin and Ambien for sleep.Reviewers Findings:  The reviewing physician found that Lyrica is not generally prescribed until it has been demonstrated that the patient is unable to tolerate high-dose Neurontin or that the patient has not benefited from high-dose Neurontin.  The reviewing physician found that he Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested alprazolam for treatment of her anxiety.  Findings:  The physician reviewer found that Alprazolam is a short-acting, highly lipophilic benzodiazepine, which means it has a rapid onset of action with a short duration of clinical effect. These basic pharmacokinetic and pharmacodynamic properties make alprazolam highly addictive and difficult for patients to discontinue once it is started. The primary care physician has written the alprazolam for daily use. However, there is no statement from either of the patients providers articulating the need for four-times daily dosing for a total of 2mg per day. In the absence of such clinical rationale, the requested alprazolam is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for fulvestrant injection and Zometa infusion. This patient has progressed on first-line therapy with Letrozole and Ibrance as part of a clinical trial. She is now being treated with second-line therapy with Zometa and fulvestrant in combination with Verzenio. Fulvestrant is indicated for treatment of HER2 negative advanced or metastatic breast cancer, in combination with Ibrance or Verzenio, in patients with disease progression following endocrine therapy. Zometa is standard therapy for patient with bone metastases. Given this support, the requested fulvestrant injection and Zometa infusion are medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medications 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 with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested the Prometheus Anser IFX test for evaluation of the enrollees Crohns disease.  Findings:  Two physician reviewers found that  medical studies support the use of therapeutic drug monitoring which is being used with increasing frequency to predict durability of response to therapies. Testing is also used to guide decision making in those patients not responding adequately to medication. Literature published over the past several years increasingly points to the benefits of therapeutic drug level monitoring as a means of preventing unnecessary exposure to medication and assisting providers to make timely decisions regarding switching medications within the same class or to another class. Several algorithms have been proposed to their use and have been widely adopted. At this point, these tests are used in centers that serve large populations of inflammatory bowel disease (IBD) patients primarily in an attempt to maximize and prolong the benefit of a very useful drug category. One groups 10 year experience identified loss of response to infliximab in line with other studies at 12% after year one and pointed to the likely relationship to development of antibodies to infliximab (ATI).. Empiric dose adjustment no longer seems reasonable in a time when data is available for guiding those decisions. This is especially true in the pediatric population where timely decision making regarding choice of drug is critical to preserving growth and decreasing the likelihood of surgery. Aside from the role for routine monitoring, several factors in this case made assessing the drug level important.  Waiting for clinical symptoms to develop in response to inappropriate or inadequate dosing in this clinical setting is not consistent with optimal management. Additionally, the provider was attempting to ascertain the role of combination therapy (methotrexate); much of the benefit of a second agent seems to come from decreasing anti-drug antibodies and given the elevated ALT while on methotrexate it would be appropriate to see whether adequate drug levels could be maintained without its use. For all these reasons, the Anser IFX test for evaluation of this patients medical condition was likely more efficacious than any available standard therapy.  Final Result:  Two reviewers determined that the testing 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 reviewers are board certified in pediatrics with sub-specialty certification in pediatric gastroenterology 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

A 62-year-old male enrollee has requested authorization and coverage for a positron emission tomography (PET) scan for evaluation of the enrollees recurring diverticulitis.  Findings:  Two physician reviewers found that the patient has a history of recurrent diverticulitis, which was previously treated surgically. The patient was also noted to have a family history of colon cancer. The patient presented with the following symptoms: intractable diarrhea, gastrointestinal bleeding, nausea and diffuse abdominal pain. A colonoscopy was performed and polyps were noted and biopsied. The colonoscopy was significant for diverticula with spasm, deformity and erythemia. The patient failed outpatient treatment and was admitted to the hospital.  A CT scan was performed and demonstrated no acute abdominal findings. The patient has requested authorization for a PET scan, which has been denied by the Health Plan. In reviewing accepted guidelines for the evaluation and treatment diverticulitis, there is no indication that PET scanning is used as a tool for pre-operative evaluation, or that it is indicated in the evaluation of intractable cases. The National Comprehensive Cancer Network (NCCN) guideline for screening for colorectal cancer recognizes colonoscopy as the primary screening tool for occult cancer. There has been some use of PET imaging in the evaluation of fevers of unknown origin, however, this continues to remain of unproven efficacy and is not in widespread use (Meller, et al.). Overall, there is no indication in the peer-reviewed medical literature that the use of PET imaging is useful in the evaluation or treatment of diverticulitis. Therefore, the requested PET scan is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center level of care provided from the date of service in question, forward. Findings:  The physician reviewer found that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Outpatient treatment and least restrictive options are considered first lines of care. Studies have shown that treatment outside of a residential setting are effective and appropriate and are as beneficial as residential programs. In this case, the patient presented to residential treatment with a history of aggression. At the beginning of the patients residential stay he was struggling with noncompliance behavior with staff and peers. Over the course of several weeks the patient had a dramatic change in his behavior. He became more polite and cooperative with treatment staff and his peer relationships improved. Although the patient requires continued treatment to further improve his social functioning and impulsive behaviors, he no longer needs the restrictiveness of a residential treatment facility as he has stabilized enough to transition to a less restrictive setting. In sum, the services at issue were not and are not medically necessary, and the patient could have been treated in a less restrictive setting safely and effectively as of the date of service in question. Final Result: The reviewer determined that the services at issue 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 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: Upheld

A 41-year-old male enrollee requested authorization and coverage of continued hand therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees hand injury.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old female enrollee requested authorization and coverage of an abdominoplasty. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees abdominal hernia.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.