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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dextroamphetamine-amphetamine salts IR 20 mg tablets, quantity 90 for 30 days. The provider noted that the patients ability to function is significantly improved with dextroamphetamine-amphetamine salts IR 20 tablets, quantity 90 for 30 days, compared to treatment at a lower dosage. Adult ADHD, particularly in patients with a history of childhood ADHD, can be significantly debilitating and requires continuous treatment. The patient requires a higher dosage given the patients tolerance, which has likely increased over time with this class of medication. The documentation supports that dextroamphetamine-amphetamine salts IR is an effective and safe treatment option for this patient based on current medical literature and recommendations (Cortese). For these reasons, the requested dextroamphetamine-amphetamine salts IR 20 mg tablets, quantity 90 for 30 days, are medically necessary for treatment of this patient.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 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 residential treatment center services for treatment of the enrollees alcohol use disorder.  Findings: The physician reviewer found that continued residential treatment center services were not medically necessary for treatment of the patients behavioral health condition. Based on the documentation provided for review, the patient did not have significant post-acute withdrawal symptoms. The patient was not a danger to himself or to others. There were no emotional, behavioral, cognitive, or impulsive symptoms. He was motivated, cooperative, and working on his treatment plan. He was medically and psychiatrically stable. His hypertension was controlled on medications. He was on anti-craving medication. In addition, there were no new problems that had arisen and there was no evidence to indicate that returning him to his environment would lead to destabilization. He did not have a repeated inability to achieve and maintain abstinence and he had support systems in place. The patient no longer met American Society of Addiction Medicine (ASAM) clinical guidelines for residential level of care and could have been successfully treated at a lower level of care such as intensive outpatient program (IOP) or outpatient. 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested services on an emergent basis.  The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with an upper respiratory infection. The patient was a non-smoker and there was no evidence of shortness of breath, weakness, hemoptysis, nausea/vomiting, or significant pain or disability. Moreover, the patient was not in acute distress and there was nothing in the patients history, physical exam, or ER evaluation that indicated any emergent or even urgent medical condition. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe he was suffering from a serious medical condition that required immediate medical attention. In sum, the patient was not experiencing 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. Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care. 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: Medical Necessity
Decision: Overturned

The patient is a 66-year-old male who is requesting authorization for Levitra (5 phosphodiesterase inhibitor) for the treatment of erectile dysfunction. The Health Plan has denied this request on the basis that the patient has no clear etiology for erectile dysfunction and therefore, the patient does not have an established diagnosis required for authorization of Levitra.The patients records document the patient has hypertension, elevated cholesterol and that he underwent transurethral resection of the prostate in 1999. The patient dates the onset of his erectile dysfunction to the prostate procedure. The patient initially had some success with Viagra but indicates that it is no longer effective. He is now seeking authorization for Levitra.Viagra and Levitra are accepted primary therapy for erectile dysfunction. Treatment of erectile dysfunction is goal directed. Treatment that is successful and acceptable to the patient and his partner is appropriate therapy. It is estimated that 50% of males over the age of 60 have erectile dysfunction.This patient has documented risk factors for erectile dysfunction, including hypertension and elevated cholesterol. He has also had a transurethral resection of the prostate, which has a small but definitive complication rate (less than 10%) of causing erectile dysfunction. For these reasons, the patient does have a medical diagnosis of erectile dysfunction.Given the fact that the patient no longer responds to Viagra and Viagra and Levitra have the same action mechanism, it is unlikely he will respond to Levitra. However, the patient should be provided a trial of Levitra to determine if it is effective.Based upon the information set forth above, I have determined that a one-month trial of Levitra is medically indicated for this patient. Therefore, the Health Plans denial should be overturned. If the trial is effective, Levitra should continue to be authorized. However, if the trial of Levitra is not effective, Levitra should no longer be authorized.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for pulsed dye laser (PDL) treatment to the left lower lip. The submitted documentation fails to demonstrate the medical necessity of the requested PDL treatment in this patients case. The medical records indicate that the lesion has been asymptomatic, but may be enlarging. There has been no bleeding. Given the lack of associated symptoms, the request for coverage of pulsed dye laser treatment would be considered cosmetic and not medically indicated. Therefore, the requested PDL treatment to the left lower lip is not medically necessary 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 dermatology 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 58-year-old male enrollee has requested Lyrica for the treatment of his severe neuropathic pain. Findings:  The physician reviewer found that Lyrica is FDA approved for fibromyalgia, some seizure conditions, diabetic neuropathy and postherpetic neuralgia. Lyrica is often used off-label for a variety of non-FDA approved neuropathic pain conditions. Gabapentin has an analogous mechanism of action and is used for many of the same conditions as Lyrica. Some patients report better outcomes on Lyrica versus gabapentin. Lyrica has a linear pharmacokinetic profile in that there is a direct linear relationship between higher doses and clinical effect. Gabapentin has a plateau effect, as higher doses may not have a directly linear increase in therapeutic effect. This patient has noted excellent benefit with Lyrica without limiting side effects.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 19-year old male with disabling chronic daily headaches who was seen at an out of state facility for additional medical opinions.  He was previously seen by many neurologists, headache specialists, and pain management physicians. The patient underwent diagnostic testing of the brain (MRI/MRV/MRA) in September 2004. The consulting neurologist reviewed these films and ordered an additional MRV with contrast, which was performed on 1/26/05.  The Health Plan denied coverage stating the MRV was not medically necessary.Review of the submitted clinical evidence indicates the patient underwent a MRV in September 2004, which included a MRV without contrast. Upon reviewing the results, the patients consulting neurologist determined a MRV with contrast was warranted to rule out superior sagittal venous sinus thrombosis and for comparison with the September 2004 MVA to better evaluate an anomaly in that study. Given the identified clinical objectives of the repeat study, I have determined the MRV at issue was medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 21-year-old female enrollee has requested reimbursement for acute inpatient psychiatric services provided over approximately seven weeks for treatment of the enrollees substance abuse, anxiety, depression, and eating disorder.  Findings:  The physician reviewer found that based on review of the available records, this patient presents with a significant chemical dependence problem that dates back to her middle childhood. This condition apparently preceded most of her mental health and behavioral problems. Consistent with the American Psychiatric Association (APA) and American Society of Addiction Medicine (ASAM) treatment guidelines, this patient was a candidate for treatment at a lower level of care during the timeframe in question. The records do not demonstrate that the patients symptoms were acute or of the severity that requires 24-hour supervision and care. The patient was not an imminent suicidal risk or danger to others, did not demonstrate acute impairment, or demonstrate self injury to uncontrolled risk taking behaviors. Therefore, by the day before the timeframe in question she did not meet the APA criteria for acute inpatient psychiatric services.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old male enrollee has requested substance abuse residential rehabilitation services for the treatment of his alcohol dependence. Findings:  The physician reviewer found that during the dates of service at issue, the patient was not in acute withdrawal, and he did not require 24/7 professional monitoring. There were no substantive medical or additional psychiatric impairments. There is no evidence that the patient was a threat to himself or others. No objective documentation that the patient had undergone prior attempts at substance abuse treatment has been provided. The patient did not meet the American Psychiatric Associations practice guidelines for treatment of patients with substance use disorders. He could have been safely and effectively treated at a lesser level of care than that which he received. The Health Plans denial was medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old female has requested hormone replacement therapy medication Vivelle-Dot for treatment of her menopausal symptoms.  Findings:  The physician reviewer found that hormone replacement therapy (HRT) is an effective treatment for menopausal symptoms, especially hot flashes and its associated symptoms such as fatigue, and sleeplessness.  In addition, HRT can be helpful for emotional instability.   When a woman has not had a hysterectomy, if estrogen is prescribed, a progesterone product also needs to be taken to prevent the development of uterine cancer, which can occur if unopposed estrogen is prescribed.  There is no information in the record to indicate that the patient has had a prior hysterectomy, and if she has not, then prescribing estrogen alone is contraindicated.Though there can be increased risks of cardiovascular complications and other risks with hormone therapy, those risks are relatively low in the younger perimenopausal and postmenopausal woman. There are also indications that transdermal therapy (i.e. patches) as opposed to oral therapy may reduce some of the clotting risks due to avoiding passage through the liver as occurs with oral intake.  However, there is no evidence that any particular transdermal route or patch is safer or superior to any other.Thus, this patient may be a candidate for hormone therapy. However, this would need to be decided after discussion of the risks and benefits of such therapy with her Ob/Gyn.  The appropriate route, dosing, and the need for progesterone therapy with the estrogen would be part of this discussion.  If it were decided that a patch was appropriate for the estrogen portion of her therapy, then the Plans formulary patch Climara would be appropriate, as Vivelle Dot has not been proven to be more efficacious in the peer-reviewed medical literature.  Climara and Vivelle Dot both deliver the same hormone estradiol, and are available in similar dose levels.  There is no medically necessary reason for her to use Vivelle Dot rather than Climara if a patch is chosen. However, this patient has not been evaluated by a Plan Ob/Gyn provider. All told, the requested Vivelle Dot medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for interventional radiology services at a tertiary level of care. This patient presents with symptomatic uterine fibroids. There are many options for treatment of uterine fibroids including hormones, hysteroscopic or abdominal myomectomy, and hysterectomy. Uterine arterial embolization provides a minimally invasive and uterine-sparing treatment option. Per the American College of Obstetrics and Gynecology (ACOG), uterine arterial embolization is an acceptable treatment option for patients who would like to avoid surgical management with hysterectomy. Ideal candidates include patients who are premenopausal, with heavy menstrual bleeding or dysmenorrhea caused by intramural fibroids, with no desire for future pregnancy. This patients records demonstrate that she meets the clinical criteria to undergo uterine artery embolization. As noted in the medical literature, uterine arterial embolization is performed by interventional radiologists who are trained in performing this specific procedure. Given these findings, the requested interventional radiology services at a tertiary level of care 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 obstetrics and gynecology 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 41-year-old man who saw his physician for painful, swollen toes secondary to thickened, crumbling toenails. The physicians diagnosis was onychomycosis. The Health Plan denied coverage for Lamisil. A fungus culture grew out coagulase-negative staph and no fungus. Liver function tests were normal. The condition worsened to the extent that the patients mobility was impaired. The patient then took Lamisil tablets for 180 days. During the course of the treatment, the nails improved, the pain and swelling disappeared, and the patients mobility was no longer impaired.The submitted clinical information is sufficient to support the diagnosis of onychomycosis. A toenail condition such as this patients with irregular crumbling and thickening and resultant painful swelling of the toe does not improve on its own. The condition worsened until the patient underwent treatment with Lamisil, at which time his symptoms improved dramatically. A negative fungus culture does not rule out a fungus infection, especially in light of the compelling clinical information presented in this case. The presence of staph in a fungus culture can mask the presence of fungus. Given the evidence provided, Lamisil was the only medication that was likely to be effective for this patient and as such, was medically warranted.For the reasons set forth above, I have determined the medication at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Tymlos. Findings:  The physician reviewer found that guidelines, patients with a fracture within the past year or while on approved osteoporosis therapy, a very low T-score defined as less than -3.0, or at high risk for falls or history of injurious falls with high fracture probability, are candidates for treatment of osteoporosis. This guideline also states that Tymlos should be considered for patients unable to use oral therapy and as initial therapy for patients at very high fracture risk. In this case, the patient has a history of multiple stress fractures in both feet as a result of osteoporosis. Therefore, she is considered a person with a very high fracture risk. According to the guideline, patients at very high risk for fracture can receive Tymlos as initial therapy for the treatment of osteoporosis. In addition, this patient is a poor candidate for oral bisphosphonate therapy due to significant reflux disease and Tymlos is appropriate in patients unable to use oral therapies. Given these findings, the requested Tymlos is medically necessary for treatment of this patient. 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 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: Upheld

The parent of a six-year-old female enrollee has requested authorization and coverage for monthly physical therapy. The health plan has denied this request on the basis that the requested services are not medically necessary for treatment of the enrollees progressive scoliosis.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

An enrollee has requested reimbursement and prospective authorization and coverage for fentanyl citrate lozenge HD. The submitted documentation fails to demonstrate the medical necessity of the medication at issue. Fentanyl transmucosal immediate release agents may be medically indicated for patients with a history of cancer-related pain and/or oral mucositis due to some types of cancers. The review by colleagues indicated that although there is some benefit for short term improvement, there are no placebo-randomized controlled trials supporting the effectiveness and safety of long-term opioid therapy for treatment of chronic low back pain. Moreover, the authors noted the very few trials that compared opioids to non-steroidal anti-inflammatory drugs (NSAIDs) or antidepressants did not show any differences regarding pain and function. This patient has chronic pain, and she reports that she is more functional with the fentanyl citrate lozenge HD. The submitted documentation indicates that the patient has been treated with fentanyl-based medications for several years. The current medical evidence does not support the medication at issue in this clinical setting, as the patient is not terminally ill due to cancer or malignancy. The medication at issue is not an appropriate treatment for this patient with chronic back pain. Other appropriate options in this patients case include cognitive behavioral therapy and buprenorphine. Therefore, fentanyl citrate lozenge HD was not and is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the medication at issue was not and 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 anesthesiology with sub-specialty certification in pain 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.