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

An enrollee has requested authorization and coverage for a Miami Adjustable LSO back brace. Medical literature does not support that LSO back braces are an effective measure to treat even severe low back pain in the absence of objective instability or in an appropriate postoperative setting. Back orthoses are generally considered contraindicated because they can promote core weakness, which is the opposite of appropriate treatment. In this case, there are no indications in the submitted documentation that the patient has a condition that requires the use of a back orthosis. The submitted records indicate that the patient has chronic, intermittent and functionally incapacitating back pain following an old, unspecified back injury. Despite the patient's symptoms, a back orthosis is not necessary or appropriate under these circumstances for the patients condition. Accordingly, the requested Miami Adjustable LSO back brace is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested durable medical equipment is not medically necessary for 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: Medical Necessity
Decision: Upheld

The parent of a 17-year-old female enrollee has requested  Holistic Bipolar treatment for treatment of the enrollees bipolar disorder.  Findings:  The physician reviewer found that the official guidelines of the American Academy of Child and Adolescent Psychiatry (AACAP) for the treatment of children and adolescents with bipolar disorder provide specific recommendations for young patients with bipolar disorder. The AACAP suggest that, Most youth with Bipolar I Disorder will require ongoing medication therapy to prevent relapse; some individuals will need lifelong treatment. Further, they recommend that, Psychotherapeutic interventions are an important component of a comprehensive treatment plan for early-onset bipolar disorder. Despite these recommendations, the AACAP do not indicate that chiropractic manipulation, herbal supplements, amino acids and a low sugar diet as part of the treatment plan for bipolar disorder. For this reason, the holistic approach requested has inadequate scientific research or evidence to establish it as an accepted treatment modality. The requested services are therefore not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a one-year-old female enrollee has requested  for a frenulectomy for treatment of the enrollees ankyloglossia.  Findings:  The physician reviewer found that the criteria for the diagnosis of tongue-tie vary and include an inability to raise the tongue tip to the upper alveolar ridge, dimpling of the tongue just behind the tip when elevation is attempted, or inability to protrude the tongue beyond the lower teeth. Most providers regard tongue-tie as significant when the shortened frenulum binds the tongue tip to the floor of the mouth so that the tongue cannot be protruded, but is merely rolled out. The release of tongue-tie, or frenulectomy, is recommended for these conditions. Except for a few infants whose poor suck is thought to be related to this condition, surgery should be deferred until four or five years of age. Most surgical releases, however, are done for cosmetic reasons as many parents regard tongue-tie as a deformity.
Appeal type: Urgent Care
Decision: Overturned

A 54-year-old male enrollee has requested for emergency services for treatment of his pilonidal cyst. Findings:  The physician reviewer found that the patients symptoms met prudent layperson criteria for emergency care. A prudent layperson with severe pain and an increased risk of infection would reasonably expect the absence of emergency care to jeopardize their health. The records indicate the patients pain was rated as 8/10 and he required significant doses of parenteral narcotics for pain control. He also has diabetes, a medical condition that places him at increased risk for severe infections such as necrotizing fasciitis
Appeal type: Medical Necessity
Decision: Overturned

A 66-year-old female enrollee has requested for an international normalized ratio (INR) machine for evaluation her Coumadin. Findings:  The physician reviewer found that this patient is on chronic Coumadin therapy to help reduce thromboembolic risk. The documentation indicates that the patients caregiver can operate a home INR monitoring device and that testing with the device would not be expected to occur more frequently than weekly since current laboratory INR draws are not occurring more frequently than once weekly.  The requested INR machine is medically indicated in this clinical setting. All told, the requested INR machine is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested chiropractic for treatment of her myospasm, dorsal segment dysfunction, and rib subluxation.   The physician reviewer found that the records indicate that this patient has had extensive chiropractic treatment. The records from the patients chiropractic visits do not include documentation and examination findings that support the medical necessity of ongoing chiropractic treatment. There are no objective measures of improvement. In addition, the provider has submitted diagnoses that are mild and should not require extensive treatment and could have been well managed with the approved visits over two months. Chiropractic care is medically necessary after a trial of treatments based on documented improvement. When further clinical improvement cannot be reasonably expected and treatment becomes supportive rather than corrective in nature then the treatment is considered maintenance therapy. Given these findings, the chiropractic services were not and are not medically necessary for treatment of this patients medical condition. 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 chiropractic and oriental 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the head for evaluation of the enrollees pain. Findings:  The physician reviewer found that there is a paucity of evidence that supports medical imaging for patients presenting with nonspecific headaches.  The American College of Radiology criteria does not support the requested MRI for this patient with chronic headache, no new features, and normal neurologic examination.  The American College of Radiology notes in adult and pediatric patients with migraine, but without recent change in attack pattern, history of seizures, or other focal neurologic symptoms or signs, the routine use of neuroimaging is usually unwarranted. The American College of Radiology reports that the yield of computed tomography or MRI in patients with headache but normal neurologic examination is low.  In this patients case, he has no localizing signs or symptoms, and he does not have a history of a primary tumor.Final Result: The reviewer determined that the requested testing is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in diagnostic radiology 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

A 55-year-old female enrollee requested AlloMap testing for medical evaluation of her status, post orthotopic heart transplantation.  Findings:  Two physician reviewers found that for low risk patients more than six months status post orthotopic cardiac transplantation, there is support for AlloMap testing in lieu of endomyocardial biopsy to monitor for acute rejection.  This is an appropriate test to obviate the need for repeated invasive evaluation post transplantation.  There is sufficient support for the use of AlloMap testing between six months and five years post transplantation.  All told, AlloMap testing was likely to have been more efficacious than other modalities.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Linzess for treatment of his slow transit constipation. The physician reviewer found that according to the documentation submitted for review, this patient presents with chronic idiopathic constipation, with reports of infrequent bowel movements, difficulty during defecation, abdominal pain, cramps and nausea. The patient reports his constipation has persisted despite opioid withdrawal. Linzess is a guanylate cyclase-C agonist that is U.S. Food and Drug Administration (FDA) indicated in adults for treatment of chronic idiopathic constipation. In this case, the patient has benefitted from use of Linzess. Thus, it is medically appropriate for him to continue with Linzess. Based on the medical literature and clinical documentation provided, Linzess is 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 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

The parents of a ten year-old male with type I diabetes mellitus are requesting reimbursement and prospective authorization of growth hormone therapy.Reviewers Findings:The reviewing physician found that the information submitted does not establish the medical necessity of growth hormone therapy.  The physician concluded that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 27-year-old female has requested the extended use of a continuous passive motion (CPM) machine for post-operative rehabilitation.  Findings:  The physician reviewer found that generally accepted standards recommend that the use of CPM devices is limited to approximately three weeks following surgery to allow scar tissue to be stretched out.  Review of the peer-reviewed literature does not demonstrate that the use of a CPM device beyond 21 days results in significant benefit beyond that which can be achieved with therapy alone.
Appeal type: Medical Necessity
Decision: Upheld

An 18-year-old male enrollee has requested reimbursement for acute inpatient psychiatric level of care services.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue.  At the time of admission, the patient was chronically depressed, and he engaged in alcohol and drug use. There is no evidence in the clinical notes indicating that the patient was acutely ill.  Passive suicidal thoughts, without active plan or intent, were identified.  The services and evaluation provided did not clearly address the patients clinical needs or provide a treatment plan that could be considered effective for the patients condition.  The medical notes do not demonstrate that the patient had failed structured outpatient treatment.  Additionally, the documentation does not demonstrate that less restrictive settings, such as intensive outpatient program services, had been considered.  In this patients case, intensive outpatient program services would have been medically necessary during the dates of service at issue. All told, acute inpatient psychiatric level of care treatment provided on the dates in question was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for inpatient mental health services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Applying the CALOCUS guideline to this patients presentation, the patient did not meet the criteria for inpatient mental health services. The patient was at significant risk of harm (score 3) due to suicidal ideation and excessive use of alcohol and other drugs resulting in potentially harmful behaviors. The patient demonstrated moderate functional impairment (score 3) given the conflict with her family, deterioration in school performance, and her inability to engage in activities of daily living. The patient has significant co-morbidities (score 3) with a history of depression and substance use disorder. The patients recovery environment was moderately stressful (score 3) considering her recent loss of a close friend, academic difficulties, and exposure to substance abuse via peers. The patients recovery environment was supportive (score 2) as her parents were noted to be actively participate in her treatment. The patient did not have any substantial prior experience with treatment (score 1) per the records provided for review. The patient was non-collaborative (score 4) in treatment, due to her actively hostile relationship with providers and her refusal to participate in treatment or take medications. This gives the patient a composite score of 19, which is consistent with high intensity community based services. This level of care includes an intensive outpatient program (IOP) that allows the patient to live at home while still receiving multiple hours of treatment per week, usually including individual, group, and family therapy. Given these findings, the inpatient mental health 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 psychiatry with subspecialty 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: Experimental/Investigational
Decision: Upheld

A female enrollee requested heat to destroy nerve tissue (CPT code 64636) at levels L3-5 for medical treatment of her lumbar spondylosis.   Findings:  Three physician reviewers found that the records provided for review do not support a clinical indication for the requested procedure at the L3-5 levels. There is a lack of documentation, such as a pain diary for the 312 hours of improvement following medial branch blocks (Derby, et al; Falco, et al). Further, this patient underwent injections at both the level above the fusion and the fusion levels and likely only obtained benefit from the injections at the level above the fusion site. Thus, the requested heat to destroy nerve tissue (CPT code 64636) at levels L3-5 is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested residential treatment center services for treatment of her behavioral health condition.  Findings:  The physician reviewer found that this case presents a complex uniqueness that manifests with a complicated level of care determination. The outpatient providers who best know this case have recommended residential treatment as the patient has not adequately responded to comprehensive outpatient based services. Further, the psychiatrist acknowledged the diagnostic challenges in discerning bipolarity from character pathology. Considering the patients symptom burden, uncertain diagnostic assessment, failure of treatment in a less restrictive setting and the clinical recommendation rendered by her treatment team, admission to a residential program would be safe, appropriate and consistent with good medical practice. This patient will require long-term specialty treatment, but a short duration of treatment in a residential setting would be reasonably expected to improve her condition, refine the diagnosis and galvanize a recovery-oriented treatment plan that can be continued in a community based setting.  The length of stay should be determined based on the patients treatment needs and clinical progress within the programmatic setting. This is of particular importance in this case as there was concern that groups may have exacerbated her illness expression in the past. Thus, the admission would be subject to standard review processes to determine the appropriate length of stay.  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 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 29-year-old female enrollee requested authorization and coverage for a wheelchair for the treatment of osteochondritis desecans of both knees. The health plan has denied this request indicating that the requested equipment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an implanted hypoglossal nerve stimulator for treatment of his obstructive sleep apnea (OSA).  Two physician reviewers found that review of the current medical literature indicates that hypoglossal nerve stimulation for treatment of OSA shows positive and beneficial outcomes with minimal adverse effect. For patients who fail CPAP trials, either no treatment or more invasive surgical treatments have been standard therapy. Some data suggests that hypoglossal nerve stimulation can result in improved health outcomes in well selected patients. However, further outcomes data, especially regarding long-term effects, is recommended before hypoglossal nerve stimulation is demonstrated to be as good as or better than standard available therapies in this circumstance. Thus, the requested implanted hypoglossal nerve stimulator is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three reviewers are board certified in otolaryngology 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested a hospital for treatment of his cyst of kidney and ureteric obstruction.  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for a hospital stay has not been established. At the time of admission the patient had stable vital signs and was afebrile. There was no indication of active infection, the urinalysis was normal. There was no documentation submitted that showed hematuria, urinary tract infection or uncontrolled pain. The documentation submitted for review does not demonstrate that the patient had problems voiding, ambulating, eating or with pain management. Upon review of the documentation submitted, the patient could have been treated at a lower level of care.  As such, the documentation submitted for review does not support that the patient required services at an inpatient level of care. For the reasons provided, the services at issue were not medically necessary. 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 internal 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.