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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage to remain in a skilled nursing facility and continue physical therapy for treatment of the enrollee, who has a history of congestive heart failure. Findings:  The physician reviewer found that This patient has a history of dilated cardiomyopathy with an ejection fraction of 20-25% and New York Heart Association (NYHA) class III-IV congestive heart failure.  He has had multiple episodes of volume overload in the last year requiring intensive diuresis.  He was hospitalized with volume overload and pneumonia. He was aggressively treated in the hospital over a week and medically stabilized.  He has been receiving care at the skilled nursing facility, primarily for deconditioning.  He had made very modest functional progress.  He was continuing to require minimum assistance for transfers and very short distance ambulation.  He continued to require minimum to moderate assistance for his basic self-care.  There are no indications in the records that the patient would have been expected to make further significant gains. Overall, his function had plateaued at a level where significant custodial assistance would have been expected for an indefinite period of time.  The patient could have returned to the community with custodial level support for assistance with basic activities of daily living and mobility or have been transitioned to longer term care. He had multiple conditions that were very chronic, but otherwise stable.  There were also stage 1 pressure injuries that were being treated conservatively.  There were, however, no documented medical or nursing issues requiring ongoing inpatient level care.  Although the medical literature generally supports subacute or skilled nursing facility level inpatient rehabilitation in a variety of clinical settings including severe cardiomyopathy, the medical literature does not support the necessity of this intervention indefinitely in the absence of expected clinically significant functional progress. The available records do not demonstrate that he had any skilled therapy, nursing or medical needs requiring ongoing inpatient hospital level care.  All told, it was not and is not medically necessary that this patient remain in a skilled nursing facility and continue physical therapy.  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 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: Upheld

A 39-year-old female has requested coverage for past and future services for formal pelvic floor therapy, electrostimulation and biofeedback therapy for treatment of her interstitial cystitis.   Findings:  Two physician reviewers found that the patient has a history of irritative symptoms that have not recently been associated with urinary tract infections (UTIs). The patient had a period of frequent UTI symptoms, which persisted despite treatment. She was found to be negative for a nuclear matrix protein 22, however, a cystoscopy did show erythematous areas. The patient has received intravesical instillations of kenalog, sodium bicarbonate, lidocaine, sterile water and heparin. The patient also underwent treatment with pelvic floor therapy, electrostimulation and biofeedback therapy.  In accordance with the American Urological Association (AUA) Guidelines, the treatment course of interstitial cystitis includes general relaxation, pain management, patient education and behavioral modification. If these first line therapies fail, the AUA recommends the following: second line treatment with manual physical therapy techniques, pain management and treatment with oral-amitriptyline, cimetidine, hydroxyzine and PPS; third line treatment with cystoscopy under general anesthesia with hydrodistension, pain management, and treatment of Hunner ulcer if present; fourth line treatment with neuromodulation; fifth line treatment with cyclosporine, intradetrusor botulinum toxin and pain management; and sixth line treatment with diversion with or without cystectomy, pain management and substitution cytoplasty. The peer reviewed medical literature has not proven instillation therapy, pelvic floor therapy, electrostimulation or biofeedback therapy to be more beneficial for treatment of interstitial cystitis than any of the  above accepted therapies, as outlined by the AUA. There is no indication in the medical records that the patient has attempted treatment with all the above standard therapeutic models without success. In the absence of evidence that the services at issue were or are likely to result in a superior clinical outcome for treatment of this patients condition compared to standard modalities, the Health Plans denial was appropriate and should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old female enrollee has requested for Nuvigil 150mg for treatment of his multiple sclerosis. Findings:  The physician reviewer found that the medical literature demonstrates that Provigil is commonly used for multiple sclerosis related fatigue and can be of benefit. Nuvigil (armodafinil) is the active R-enantiomer of the racemic drug modafinil, with a significantly longer half-life than the S-enantiomer. Other alternatives include amphetamine or Ritalin, neither of which have been shown to specifically be of benefit for this purpose.  Nuvigil 150mg was and is medically indicated for this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for weight loss surgery (endoscopic bariatric surgery). Current medical literature does not support endoscopic pouch reduction as a durable treatment for morbid obesity. Overall, the durability of the requested procedure has not been consistently documented in published studies. Although some patients report short-term weight loss, there is a paucity of high-level data demonstrating long-term patient health outcomes. With regard to this patient, the records document prior Roux-en-Y gastric bypass. The patient was able to maintain his weight loss for several years. The provider reports that this patient has gastric pouch enlargement. The physician reviewer found that  endoscopic treatments for this condition have not been shown to result in weight loss for more than three years. By adopting dietary recommendations, the patient was able to lose nine pounds in one week. Given these findings, the requested weight loss surgery (endoscopic bariatric surgery) is not medically necessary for 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral Euflexxa injections. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patients treatment options are limited. Corticosteroid injections and physical therapy have not been successful. The patient is not an ideal candidate for bilateral total knee replacements as the osteoarthritis is most severe in the patellofemoral compartment and relatively mild in the medial and lateral compartments. For these reasons, the requested bilateral Euflexxa injections are medically necessary for 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Rituxan for treatment of the enrollees systemic lupus erythematosus (SLE). Findings: The physician reviewer found that this patient presents with a history of SLE, achalasia, gastroparesis and neurogenic bladder. There are two randomized controlled trials evaluating the use of Rituxan in patients with moderate to severe SLE which failed to demonstrate significant benefit compared to placebo. Merrill and colleagues reported that no differences were noted between placebo and rituximab in the primary and secondary end points. Further evaluation of patient subsets, biomarkers, and exploratory outcome models may improve the design of future SLE clinical trials. Rovin and colleagues reported on the lupus nephritis assessment with Rituxan (LUNAR) study. The authors concluded that Rituxan did not improve clinical outcomes after one year of treatment. Currently, the literature does not support its use in this clinical setting. Accordingly, the requested Rituxan is not medically necessary for treatment of this patients diagnosis of SLE.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 rheumatology 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 54-year-old male with localized T1c prostate cancer. The patient has decided to pursue radical prostatectomy for treatment of his prostate cancer. The patient wishes to have this procedure performed using the laparoscopic technique. The Health Plan denied authorization and coverage for a laparoscopic radical prostatectomy on the basis the requested procedure is not medically necessary for treatment of the patients prostate cancer.Laparoscopic radical prostatectomy has proven to be safe and effective for the treatment of prostate cancer. It has demonstrated similar oncologic results to open prostatectomy. The laparoscopic procedure has advantages over the open procedure in that it involves reduced blood loss, less pain, and more rapid recovery (short- and long-term) compared to open surgery. It appears the patient is an appropriate candidate for laparoscopic radical prostatectomy. In light of the advantages of the laparoscopic procedure compared to open surgery, the laparoscopic procedure is medically appropriate and indicated for this patient. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The representative of a 17-year-old female enrollee  requested authorization and coverage of continued inpatient behavioral health care for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees behavioral health problems.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 54-year old male with a history of chronic neck and back pain resulting from a slip and fall in his bathtub in August 2004.  According to the patient, traditional treatment, i.e., physical therapy and medication, had not given sustained relief.  He did however report that he had benefited from acupuncture treatments.  The patient had 12 acupuncture treatments and has requested authorization for additional treatments.  He also had open-heart surgery in February 2005 and does not want to be dependent on heavy medication.  The Health Plan has denied his request for additional acupuncture treatments as not medically necessary.The patient had 12 acupuncture treatments from April 2005 through August 2005 and states these treatments have given him relief from pain and he had been able to reduce his pain medications.  Unfortunately, the treatment notes for these dates do no reflect any change in his symptoms with the exception of the July 2005 notes, which do indicate some pain relief and reduction of medications.  The provider notes after that date only indicate low back, neck and shoulder pain.  There is no indication in the records of whether the symptoms have improved or worsened with the additional treatments.   Therefore, based on the lack of outcome information in the submitted records, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for artificial disc arthroplasty (CPT code 22857  total disc arthroplasty (artificial disc), anterior approach). The U.S. Food and Drug Administration (FDA) approval for the ProDisc-L total disc replacement states that the device is indicated for patients with spinal arthroplasty who are skeletally mature, have degenerative disc disease at one to two levels in the lumbar spine from L3 to S1, have no more than grade 1 spondylolisthesis at the involved level, and have had no pain relief after at least six months of non-surgical treatment. FDA exclusions include active systemic or site infection, osteopenia or osteoporosis, bony lumbar spinal stenosis, isolated radicular compression syndromes especially due to disc herniation, and pars defect. Buttner-Janz and colleagues noted with respect to safety, there was good agreement in the medical literature to exclude patients with osteopenia or fracture. Zigler and Delamarter concluded that patients undergoing both ProDisc-L total disc replacement and circumferential arthrodesis for the treatment of single-level degenerative disc disease maintained significant improvement during the five-year follow-up. This patient is being treated for L5-S1 discopathy, spondylotic stenosis. She presents with severe low back pain radiating to the right leg and left lower extremity paresthesias. She reports that her persistent and intractable low back pain negatively affects her ability to get out of bed. Her range of motion has become restricted as her chronic pain has worsened. Documentation reveals that she has failed conservative treatment for six months with continued pain and symptoms. However, there is evidence of multi-level disc degeneration at the thoracolumbar region. These highly degenerative disc levels represent significant unaddressed plausible pain generators in this patient. There are also clinical and imaging findings of radicular pain syndrome due to recurrent disc herniation, which is an FDA associated contraindication. For these reasons, the requested artificial disc arthroplasty (CPT code 22857  total disc arthroplasty (artificial disc), anterior approach) is not medically necessary for 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 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: Upheld

The patient is a 61-year-old female who sustained a fractured right femur and is status post open reduction and internal fixation. She also has a complex medical history, which includes atrial fibrillation, hypertension, diabetes mellitus, coronary artery disease, hypothyroidism and schizophrenia. She needed maximum assistance with bathing and dressing. She also required assistance with transfers and ambulation, as she was unable to ambulate by herself. She made no progress during her stay in August 2005 so occupational therapy was discontinued. The patient is seeking coverage for further SNF services.The patient is clinically stable. The patient has no on-going daily skilled nursing needs and there is no documented progress with physical therapy or occupational therapy. In addition, there is no evidence that currently the patient is able to benefit from physical or occupational therapy. Because the patient is clinically stable, has no daily skilled needs, and is not benefiting for rehabilitation therapy, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 40-year-old female enrollee has requested TMS therapy for treatment of her major depression, recurrent, severe, with quality of melancholia.  Findings:  Two physician reviewers found that the peer-reviewed literature addressing the topic of antidepressant treatment consists of varying reports on the efficacy, especially long-term, and potential side effect profile along with case selection for benefit of repetitive TMS.  Gross and colleagues provided an updated meta-analysis of studies related to this treatment modality.  Their conclusions report that although results are suggestive that TMS has significant antidepressant effects, larger multicenter studies are necessary to confirm these trends. Lam and colleagues concluded that for patients with treatment-resistant depression, TMS appears to provide significant benefits in short-term treatment studies. However, the relatively low response and remission rates, the short durations of treatment, and the relative lack of systematic follow-up studies suggest that further studies are needed before TMS can be considered as a first-line monotherapy treatment for treatment-resistant depression.  In sum, at this time, the current medical evidence has not established that the requested TMS is likely to be of greater benefit than other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 26-year-old female with chronic pain due to fibromyalgia. She has requested additional physical therapy after receiving 83 visits. The Health Plan has denied the patients request on the basis that continued physical therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld. There is no objective documentation demonstrating the patient requires continued supervision by a physical therapist. The patient has received 83 physical therapy visits. This is an adequate amount of time to learn a home exercise program of myofascial release, stretching, progressive strengthening, body mechanics, and postural control. The goal of physical therapy for patients such as this patient is to teach patients how to independently manage their symptoms. The information provided demonstrates the patient can be safely and effectively treated through a home exercise program. Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 57-year-old male has requested transcranial magnetic stimulation (TMS) for treatment of his depression.   Findings:  Two physician reviewers found that the patient presents with a two-year history of reportedly severe mood symptoms. The symptom complex consists of depressed mood with a negative self-concept and hopelessness, anhedonia, sleep problems, apathy, poor motivation, and suicidal ideation. In terms of treatment, the patient has reportedly completed 20 sessions of cognitive behavioral therapy. There is no mention of treatment in a setting other than the outpatient venue. The records indicate that electroconvulsive therapy  (ECT) is contraindicated due to the patients poor tolerability of general anesthesia. The patient has trialed fluoxetine, bupropion, venlafaxine, duloxetine, aripiprazole, quetiapine, and lithium. Psychopharmacotherapy has failed to achieve remission. Due to persistent affective symptoms, transcranial magnetic stimulation (TMS) therapy was recommended.  TMS is supported in the peer-reviewed medical literature in well selected patients with major depressive disorder. Further, TMS is endorsed by the American Psychiatric Association (APA) in its current clinical practice guideline for the treatment of patients with depression. In this particular case, the patient has an enduring unilateral mood disorder with an affective symptom complex. He has trialed appropriate psychotropic medications and augmentation strategies, and has participated in cognitive therapy, which is a trusted evidence-based psychotherapy utilized in the treatment of major depressive disorder. Finally, the patient has a contraindication to ECT. All told, the current practice guidelines and relevant peer-reviewed literature support TMS as likely to be more beneficial for treatment of the patients medical conditions than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old male enrollee has requested low-dose helical computed tomography (CT) for evaluation of his chronic shortness of breath. Findings:  Two physician reviewers found that the requested diagnostic procedure is not likely to be superior over other available methods of evaluation.  Per the current medical evidence, identifying early lung cancers using annual low-dose computed tomography (CT) screening can be beneficial in select patients.  The American Association for Thoracic Surgery recommends annual low-dose CT screening for patients age 55 to 79 with a 30 pack-year history of smoking.  This patient has a 24 pack-year history of smoking and quit smoking 22 years ago.  Thus, he is not considered to be in the high-risk group which would warrant CT scanning to screen for lung cancer.  Therefore, the requested low-dose helical CT is not likely to be of greater benefit than other methods for evaluating this patient.