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 weekly counseling appointments with a provider specializing in eye movement desensitization and reprocessing (EMDR).Findings:  The physician reviewer found that the patient is a high medical services utilizer, driven by her psychiatric issues, which have not been addressed given that she is not currently in individual psychotherapy. The patient would benefit from psychotherapy, including and particularly weekly individual psychotherapy with EMDR, given her diagnosis of post-traumatic stress disorder (PTSD) and continued trauma-related symptoms. The American Psychological Association (APA) guidelines provide specific recommendations for EMDR for patients with PTSD. Additionally, in the International Society for Traumatic Stress Studies guidelines, EMDR is considered a valid option for the longer-term treatment of this complex disease entity. Overall, there is adequate support in the peer-reviewed medical literature and practice guidelines to support a trauma-focused psychotherapy as standard of care for PTSD, which includes EMDR. Given this patients trauma history, symptoms of PTSD which have been unabated, and continued difficulty with functioning as well as motivation for psychotherapy, individual psychotherapy utilizing EMDR is an appropriate treatment approach. Moreover, the requested weekly psychotherapy with EMDR is in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, the requested weekly psychotherapy with EMDR is 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 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 58-year-old female enrollee has requested custom molded diabetic shoes and multi-density inserts for treatment of her foot deformity secondary to diabetes mellitus.  Findings:  The physician reviewer found that while diabetic shoes and insoles are noted to reduce foot amputation risk, certain criteria must be met in order for the devices to be considered medically necessary. The progress notes do not document that this patient has any of the conditions which may be an indication for the requested custom molded diabetic shoes and multi-density inserts. The guidelines suggest a patient have a personal history of foot amputation, previous foot ulceration, pre-ulcerative callous, neuropathy with callous formation, foot deformity, or poor circulation in order to be considered for diabetic shoes. With regard to this patient, a diagnosis of plantar fasciitis and findings of heel spur are not foot deformities, and do not solely qualify a patient for diabetic shoes and insoles. As such, the requested equipment is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting authorization and coverage for residential treatment center (RTC) level of care. The enrollee has a history of substance abuse, borderline personality disorder, eating disorder, depression, suicidal ideation, and suicide attempts. She has a long history of outpatient treatment and 12-step programs. She was hospitalized after presenting with suicidal ideation and a plan to harm herself. She transferred to an intensive outpatient program, but program staff determined she required a higher level of care. She entered the residential treatment center level of care. During her admission evaluation, she reported her substance abuse had escalated to daily use of cocaine, marijuana, and alcohol. She reported work stress and was concerned about losing her job. Her diagnoses on admission were major depressive disorder (recurrent, severe), cocaine and cannabis use disorders (moderate-severe), and borderline personality disorder. The enrollee received individual and group therapy as well as psychopharmacology management. She participated in treatment and was compliant with medications. She remained very anxious, with dysphoric mood and restricted affect. Therapy sessions included coping skills and tools for increased confidence in asking for help. Two days before discharge, she denied suicidal or homicidal ideation and any thoughts of self-harm, but believed she needed more time before transitioning to an intensive outpatient program. She discharged to a partial hospitalization program. The enrollee drinks alcohol daily and denies a history of alcohol withdrawal seizures or delirium tremens. While at the residential treatment center, she was participating in treatment and her medications were adjusted. She had passive suicidal ideation while in the residential treatment center, but denied suicidal ideation at the time of discharge. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. The enrollees composite LOCUS score correlates with medically monitored non-residential services. Medical evidence does not support the service at issue in this clinical setting.Final Result: The reviewer determined that the requested service was not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an RTS300 FES Therapy System.Findings: In this case, the patient suffered a spinal cord injury. The patient has undergone therapies to strengthen and improve function. The evidence for the effectiveness of the RT300 functional electrical stimulation (FES) cycling in patients with spinal cord injuries is limited. There is insufficient evidence in the literature that supports that the use of the RT300 FES will be effective for this patients spinal cord condition or in individuals with quadriplegia in long term improvement of muscle strength, vascular blood flow, bone mineral density, reduction of spasticity and atrophy, facilitation of functional motor movement or reduction muscle atrophy in the upper and lower extremities. Accordingly, the requested RTS300 FES Therapy System 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, with subspecialty 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

An 81-year-old female enrollee has requested skilled nursing facility services for the treatment of her clostridium difficile colitis. Findings:  The physician reviewer found that the patient did not progress with PT. However, she showed steady progress with OT and needed to complete her training program with the trapeze to improve her bed mobility. The days in question were used to provide OT, and they were properly provided.
Appeal type: Medical Necessity
Decision: Overturned

A 72-year-old male enrollee has requested authorization and coverage for Celebrex 200mg.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication.  This patient has signs and symptoms consistent with spinal stenosis.  He has low back pain with radiculopathy and evidence of canal stenosis at L4-5.  In this clinical situation, treatment would include medical therapy with NSAIDs or COX-2 inhibitors, and conservative therapies such as physical therapy, massage or chiropractic care.  Interventional treatment modalities would include epidural steroid injection therapy, nerve blocks or consideration for surgical intervention. The documentation indicates that the patient has a history of gastrointestinal intolerance to NSAIDs.  He requires analgesic therapy. The requested COX-2 inhibitor, Celebrex, is medically appropriate in this clinical scenario.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for osteochondral graft plug. Researchers concluded that the use of an osteochondral allograft is a desirable treatment option for end-stage degenerative joint disease of the first metatarsophalangeal joint. Researchers also concluded that autologous osteochondral plug transplantation represents a potentially successful surgical option in preserving the metatarsophalangeal joint in patients in which conservative and surgical treatments have proved to be ineffective. This patient presents with persistent disabling left second toe pain and dysfunction. Her walking tolerance and activities of daily living are significantly limited. She has sustained multiple traumas to the left second toe over the past several months with acute onset of pain, swelling, and bruising. Clinical examination findings are consistent with radiographic evidence of a left second toe displaced Cartiva implant, medial wall fracture, and fracture fragment impeding dorsiflexion. The provider has recommended a salvage procedure to restore near-normal anatomy, allowing for normal second toe function and preservation of other foot structures. The alternative is removal of the metatarsal head, which would cause significant functional limitations. In this case, the osteochondral allograft plug in an attempt to restore normal function and pain management. Therefore, the requested osteochondral graft plug is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested osteochondral graft plug is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested medical device is 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: Overturned

A 52-year-old female enrollee requested authorization and coverage of breast reduction surgery.  The health plan denied the enrollees request indicating that the requested surgery is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old female enrollee has requested continued residential treatment for her anorexia nervosa, bipolar I disorder, and obsessive-compulsive disorder.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the services at issue.  Despite comprehensive outpatient services, the patient was extraordinarily distressed and had a triad of serious psychiatric comorbidity upon presentation.  Although the patient had gained weight, based on the providers notes in this case, the patient had not approached embracing the concept of recovery until recently.  Her profound anxiety burden, along with her rigidly persistent distorted schemas which impacted her mood state, necessitated the addition of a sixth psychotropic medication on the said date.  On the date in question the patient was dissociating at meal time and resentful of eating.  On the said date, she endorsed a distorted body image, and the mental status examination noted self-hatred and irrational thinking.  Based upon the medical records, discharge would have more than likely resulted in undue morbidity and a failure of treatment consolidation.  All told, continued residential treatment during the said timeframe was and is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old man with a well-documented history of obstructive sleep apnea. His previous treatment with tonsillectomy and uvulopalatopharyngoplasty has not solved the problems. The patient is intolerant of CPAP. There is no record of treatment with dental occlusal splints. There is a history of significant obesity. A request has been made for orthognathic surgery.Review of the submitted documents indicates there is no history of maxillomandibular deformity requiring correction with orthognathic surgery. The proposed orthognathic surgery (Lefort I maxillary osteotomy and bilateral mandibular ramus sagittal split osteotomies with bimaxillary advancement) is not medically indicated because more conservative surgical treatment involving repositioning the tongue and floor of mouth musculature including the suprahyoid musculature has not yet been carried out. If successful, it would obviate the need for orthognathic surgery. Also, there appears to be no demonstrable mandibular deformity or malposition that is contributing to the problem and therefore, there is no obvious need to proceed with orthognathic surgery. Furthermore, the patient is obese, which may be a major contributing factor and the obesity problem should be resolved before further surgical intervention. Based upon the information set forth above, I have determined that the requested procedure is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with osteoarthritis. Findings:  The physician reviewer found that the patient had excellent pain relief from previous viscosupplementation injections with her pain relief lasting approximately one year. The patient has requested authorization and coverage for Supartz injections. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Supartz injections in the knee are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is not known which individuals will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient had an excellent response to prior viscosupplementation. The patient has tried and failed conservative treatments, with the alternative being a total knee arthroplasty. Medical evidence supports the requested services in this clinical setting. Therefore, Supartz injections in the right knee 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: Experimental/Investigational
Decision: Upheld

An enrollee has requested authorization and coverage for RT300 functional electrical stimulation (FES) cycle therapy system for treatment of the enrollees medical condition. Findings:  The physician reviewers found that the requested device is not likely to be more efficacious than other treatment options, such as resistance-based circuit training, wheelchair ergometry or arm cranking ergometry.  Patients with spinal cord dysfunction have reduced aerobic capacity, increased incidence of being overweight, and reduced upper body strength.  Addressing these issues is of substantial importance to reduce the risk of comorbid medical issues.  Resistance-based circuit training provides cardiorespiratory and strength benefits in people with paraplegia.  There is evidence that upper body resistance circuit training, arm cranking ergometry, wheelchair ergometry, and FES cycling may improve cardiovascular health.  However, there is a lack of robust clinical studies identifying superiority of FES cycling versus the other types of exercise.  Furthermore, in regards to spasticity, there is a lack of studies indicating that FES cycling is superior to standard treatments for spasticity. Final Result: Two of three reviewers determined that the requested device is 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: Physician reviewers number one, two, and three are board certified in physical medicine and rehabilitation and is 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 nine-year-old male who has been diagnosed as autistic and depressed. The patients parent indicates the patient has benefited from treatment with Celexa. The patients parent reports the patient is more aggressive on generic drugs. The Health Plan indicates there is no evidence Celexa is medically necessary for the patient.At issue is the brand name Celexa versus generic citalopram for treatment of a nine-year-old male. Though the patients parent indicates citalopram has not been effective, there is no documented evidence a higher dose (+10 mg/d) of citalopram has been tried to see if the patient improves. Furthermore, review of the medical literature does not provide sufficient evidence of the superiority of the brand name over generic for this medication.Therefore, I have determined that the requested medication is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for eight weeks for treatment of the enrollees hepatitis C virus. Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni for eight weeks is medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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.