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

The patient is a 69-year-old male with diabetes, hypertension, heart disease and severe peripheral vascular disease. He also has a worsening ischemic/neuropathic heel ulcer. Angiogram confirmed severe disease below the knee with no distal target vessels, heel ulcer 4 x 4 cm in size, and necrotic tissue requiring antibiotics.The patient was examined by a vascular surgeon who recommended a below the knee amputation. He then consulted an out-of-plan vascular surgeon who has offered a popliteal dorsalis pedis bypass. It appears the patients current condition is non-healing arterial insufficiency/neuropathic ulceration. The patient wishes to avoid amputation and therefore, has requested authorization and coverage for a popliteal dorsalis pedis bypass. The Health Plan has denied coverage for the requested procedure on the basis it is not medically indicated for treatment of the patients condition.The patient has severe peripheral vascular disease and ischemic/neuropathic heel ulcer. A report by the patients radiologist and the in-plan vascular surgeon confirm no distal targets for bypass. Therefore, a below-the-knee amputation was offered. The out-of-plan vascular surgeon has offered a distal bypass though noted the angiogram was of poor quality. Approximately 10% of vascular patients have unreconstructable disease. This decision is based on the subjective opinion of the vascular surgeon. However, when no apparent named distal vessels are seen on angiogram, a distal bypass is unlikely to be successful. A large heel ulcer even with a well functioning bypass often requires coverage with a myocutaneous flap. Based upon the information provided, the requested procedure is not likely to be of benefit and therefore, is not medically necessary. However, a second opinion from an in-plan vascular surgeon using higher quality views of the angiogram would be medically reasonable and appropriate prior to below-the-knee amputation. Based upon the information set forth above, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 20-year-old female who has had an eating disorder since she was 13 years of age. She has retained her ideal body weight but has induced significant changes in weight by restriction and binging. The record indicates that in January of 2006 the patient moved to New Mexico to attend college. She had a personal crisis in March 2006 and her eating disorder was reactivated. She returned to California in April 2006 and was living with her parents.  She entered a specialized intensive outpatient program (IOP) for eating disorders in May 2006 and continued to attend this program through July 2006. The patient reports that she continued to experience symptoms of an eating disorder, anxiety and depression. Additional notations in the record state that she was still eating erratically, suffered from body dysmorphia, had transient suicidal thoughts, had thoughts about self-mutilation and continued to manipulate her diet with periods of no food, then binging.The patient has requested reimbursement for the IOP for eating disorders she attended from May 2006 through July 2006.  The Health Plan denied the requesting citing a lack of medical necessity for the IOP level of care.The patient has a seven year history of an eating disorder and went into crisis after the loss of a significant relationship. She became socially withdrawal as manifested by dropping out of school and returning to live at home with her parents. A recommendation was made that the patient enter a residential program. The IOP was selected as the least restrictive program that could potentially be effective. The patient was appropriate for the IOP level of care when admitted in May 2006 despite the fact that she had not been previously hospitalized. The records reflect that the patient received intensive treatment including individual, group and family therapy modalities.  By July 2006 she was no longer having suicidal thoughts or demonstrating self-injurious behaviors. She remained apprehensive regarding the transition to less intensive outpatient treatment and it was necessary to consistently reinforce treatment recommendations. Her IOP mental health provider recommended that future therapy address long-term issues and indicated a readiness for standard outpatient care. The termination of IOP care after July 2006 does not dismiss the need for the patient to continue individual therapy at a frequency that may need to exceed one time per week. Continued oversight and medication management by a psychiatrist is consistent with the standard of care.  Based upon the information set forth above and the supposition that the patient was discharged from the IOP in July 2006, I have determined the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 35-year-old female who has requested continuation of Provigil for treatment of idiopathic hypersomnia based upon a previous polysomnography. The patient has been on Provigil for approximately one year. The Health Plan has denied coverage for Provigil on the basis it not medically necessary for treatment of the patients medical condition.The patients clinical history contends there is a sleep study documenting narcolepsy; however, the documentation actually suggests restless leg syndrome. Thus, the recommended alternative of caffeine products may aggravate the patients underlying condition. Furthermore, the patients multi-latency sleep study indicates a short onset to sleep of 1-1.5 minutes, suggesting significant sleepiness. Clinically, there is an inference of risk of falling asleep while driving. Provigil has been an effective therapy for the patient. Given the patients therapeutic response, continued treatment with Provigil is medically appropriate and indicated. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees moderate receptive language delay, severe expressive language delay and severe speech delay.  Findings:  The physician reviewer found that Nelson and colleagues noted that speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  Per these authors, identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  The current medical evidence indicates that speech and language delay must be taken seriously in young children, as the long-term consequences may be substantial. According to Law and colleagues, 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, behavior, socialization and school attainment.  McLaughlin noted that there are good data available to support the effectiveness of speech-language therapy, particularly for children with primary expressive language disorder. This patient has mild to moderate receptive language delay and severe expressive language delay that are significantly impairing his ability to communicate effectively.  The medical literature supports the requested speech therapy in this clinical situation.  All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the acute rehabilitation services. The Health Plan has denied this request indicating that the requested services were not medically necessary for treatment of the patients stroke. The submitted documentation does not support the medical necessity of the services at issue. In this patients case, the clinical record does not support justification of additional acute inpatient rehabilitation services beyond the physicians and interdisciplinary teams recommendations for discharge to home with assistance. The required family education and training was completed in preparation for the patients discharge. The physicians and interdisciplinary teams recommendations for discharge were based on objective review of the patient's progress toward rehabilitation goals, prognosis stroke recovery, and recommended discharge disposition to home. Therefore, acute rehabilitation services were not medically necessary for treatment of this patient. 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and authorization and coverage for intravenous immunoglobulin (IVIG) treatment September 2017 to August 2018 and going forward; and requested reimbursement and authorization and coverage for Rituxan February 2018 to May 2018 and going forward. The Health Plan has denied this request indicating that the requested services at issue were and are not medically necessary for treatment of autoimmune limbic encephalitis, autism, and Aspergers syndrome.Researchers noted that autoimmune proven encephalitis is associated with antibodies that respond to therapy for antibodies with IVIG as primary therapy treatment.  IVIG is supported as reducing antibodies and improving inflammatory response. Researchers noted that IVIG is beneficial for treatment of immune response causing inflammation related to immune response encephalitis. Autoimmune limbic encephalitis is a relatively rare condition for which treatment is directed at immune modulation. Scientists reported Rituximab is effective and safe as a second-line immunotherapy for autoimmune limbic encephalitis (ALE), regardless of autoantibody status. Researchers noted treatment included first-line immunotherapy, second-line immunotherapy, and tumor removal if found.The records documented support for the diagnosis of antibody proven autoimmune encephalitis.  The condition was reported to have not responded to IV steroids.  IVIG was and is medically necessary to improve medical condition.  The reports indicate some improvement with IVIG such that Rituxan was added.  The patient has shown improvement since Rituxan was added.  Peer reviewed literature reflects many patients with this disease require IVIG as a treatment but also up to 50% of patients have less than adequate response and require other therapy with Rituxan being most common secondary treatment.  As such, both IVIG and Rituxan were and are medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services were and 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 neurology with a subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral Durolane (Hyaluronan) injectionsAn exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, there is a history of lasting benefit from prior Durolane injections. Furthermore, the options are limited. The patient has tried and failed other conservative treatments with the alternative being bilateral total knee arthroplasties. Therefore, bilateral Durolane (Hyaluronan) injections 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

The patient is a 58-year-old female with a history of major depression, recurrent.  She initially presented for psychiatric treatment of her depression with symptoms of anhedonia, anergia, persistent sad mood, irritability, and hopelessness. Her family history is notable for depression and bipolar disorder in first degree relatives. Previous medication trials included Effexor XR, Gabapentin, lithium and Levoxyl.  Over the next two years Effexor was discontinued in favor of Cymbalta and Abilify was added and there was improvement in the patients mood. However, she was left with a degree of anergia for which Provigil was prescribed. The patients provider reports significant gains with Provigil and a return of depressive symptoms when Adderall was substituted for Provigil. The patient again improved when samples of Provigil were provided.The patients provider has requested authorization for continued treatment with Provigil. The Health Plan has denied this request based upon a determination that the medication is not medically necessary.The addition of Provigil to the patients antidepressant regimen is a rather benign supplementation that clearly seems to have helped her. The medication was prescribed on a test/retest basis, and its benefit was far superior to Adderall. Current literature supports the use of Provigil as an antidepressant adjunct, and the prescription in this case is medically indicated. As such, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested medical transport to orthopedic physical therapy twice a week for eight weeks for the treatment of his shoulder bone spur. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. The records do not indicate that the patient has any health, physical or other functional impairments that would preclude ambulation, driving or taking public or private transportation to his appointments. A left shoulder bone spur would not preclude him from these activities. Physical activity, moreover, is generally appropriate and recommended for conditions such as asthma, hypertension, hypercholesterolemia, diabetes, obesity, and for general musculoskeletal health.  All told, the requested medical transport to physical therapy twice a week for eight weeks is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation, 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 a female enrollee has requested authorization and coverage for vertebral body tethering fusion-less spinal surgical procedure.Findings:  Two of the three physician reviewers found that in this case, the records document congenital vertebral anomalies and infantile scoliosis. The provider has requested fusion-less vertebral body tethers to correct the severe curve which measures 67 degrees at this time. Compression-based fusion-less tethers are an alternative to conventional surgical treatments of pediatric scoliosis. Anterior approaches place an anterior tether on the anterolateral convexity of the deformed spine to modify growth. Posterior tethers have also been performed. Anterior vertebral body tethering is a promising new technique for correction of the curve. It is a growth modulation technique, which utilizes the patients growth to attain progressive correction of the scoliosis. In this patients case, vertebral body tethering is likely to be a less risky alternative than other treatment options. Therefore, vertebral body tethering fusion-less spinal surgical procedure is likely to be more efficacious than other treatment options.Final Result: The 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 1, 2 and 3 are board certified in orthopedic surgery 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: Upheld

The patient is a 55-year old male with a history of left hand pain and numbness who underwent uncomplicated carpal tunnel surgery (CPT Code 64721) in January 2006. The surgery involved decompression of the left median nerve and limited flexor tenosynovectomy. The services of an assistant surgeon were utilized for the procedure and the patient is requesting reimbursement for the cost incurred.  The Health Plan denied his request based upon their determination that a surgical assistant was not medically necessary.According to the American College of Surgeons, an assistant surgeon is sometimes necessary for CPT Code 64721. The operative note in this case does not document any added complexity that would have necessitated an assistant surgeon for this patients procedure. The majority of hand surgeons do not utilize an assistant for open carpal tunnel release surgery, as this type of surgery can generally be performed with self-retaining retractors and assistance from a surgical nurse. For these reasons, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested authorization and coverage for Xifaxan for treatment of the enrollees small intestinal bowel overgrowth. Findings:  The physician reviewer found that there has been some recent literature linking SIBO to irritable bowel syndrome as well as dyspeptic symptoms. The most cited papers were published using Xifaxan as the active treatment arm compared to placebo. The medication is known to have a low systemic absorption and favorable side effect profile. However, it is clear that other antibiotic drugs will also successfully treat SIBO. The patient is allergic to sulfa and therefore Bactrim is not a treatment option. However, the use of metronidazole along with ciprofloxacin or a tetracycline would likely be as effective as the requested Xifaxan, and is covered by the Health Plans formulary. For these reasons, the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee requested authorization and coverage of bilateral knee arthroscopies. The Health Plan  denied the request indicating that the requested procedures are not medically necessary for treatment of the enrollees knee pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedures are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intravenous (IV) ceftriaxone sodium per 8.0 units daily 250 mg for 90 days.  Findings:  The physician reviewer found that per the Infectious Diseases Society of America (IDSA) guideline, treatment with ceftriaxone is recommended for patients with neurolyme. This patients records do not include documentation of cerebrospinal fluid (CSF) infection with Lyme disease. In addition, the IDSA guidelines recommend treatment for a maximum of 30 days. Extended regimens have not been adopted into mainstream guidelines. Accordingly, the requested IV ceftriaxone sodium per 8.0 units daily 250 mg for 90 days is not supported as medically necessary for treatment of this patients medical condition. 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 internal medicine with sub-specialty certification in infectious diseases 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.