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

A 48-year-old female enrollee has requested surgical removal of excess skin on her thighs/legs, arms and abdomen for the treatment of her excess skin. Findings:  The physician reviewer found that the patients condition does not meet the American Society of Plastic Surgeons criteria for third party coverage of skin resection following massive weight loss.  According to the ASPS Position Paper Treatment of Skin Redundancy Following Massive Weight Loss, skin resection is medically necessary if panniculitis or uncontrollable intertrigo is present.  The records do not document panniculitis or the failure of medically supervised conservative therapy to control this patients intertrigo. The patient also does not meet the 2007 Apollo managed care guidelines for a skin resection.  According to these guidelines, skin resection is medically necessary if the pannus hangs below the pubis and chronic intertrigo is present and remains refractory to conservative medical therapy for at least three to six months.  The records do not document three to six months of physician supervised medical management for intertrigo.  Physician supervised treatment is the simplest and safest method of managing this patients problems, and conservative treatment with appropriate hygiene and topical medications has a reasonable likelihood of correcting her condition. The most appropriate treatment for this patient is an evaluation by a dermatologist or internist with appropriate, physician directed skin care.  Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is not the case for this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a nine-year-old male who had difficulty learning to read during first grade. He was diagnosed as having a central auditory processing delay by a speech therapist. The patient has received speech therapy since March 2002. The patients speech therapist documented delays in auditory memory, interpretation and processing. A request has been made for authorization and coverage for speech therapy. The Health Plan indicates that speech therapy is not medically necessary for treatment of the patients clinical condition.Though central auditory processing disorder has been described in the medical literature, the neuropsychologic nature of the disorder is still ill defined and the true nature of the disorder remains unclear. As a result, appropriate treatment has not been well established and no techniques have been validated. In the case of this patient, an initial evaluation was performed documenting deficits, but goals for improvement were poorly outlined and were not correlated to documented deficits. Thus, the degree or extent of the patients improvement is unclear. Additionally, the stated goals were educational in nature and not medically related. Given the uncertainty associated with this diagnosis and the difficulty with developing medically related goals, there is insufficient evidence that speech therapy is medically indicated for treatment of the patients condition.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a thirteen year-old male with optic dysplasia and idiopathic short stature is requesting reimbursement and prospective authorization and coverage for growth hormone (GH) therapy.  Reviewers Findings:The reviewing physician found that although the patient is clearly short for his age, the delayed bone age projects a normal adult height and the patient has not been shown to be GH deficient.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting reimbursement for substance abuse residential treatment center level of care. The enrollee has diabetes mellitus, bipolar disorder, post-traumatic stress disorder, major depressive disorder, and opioid use disorder. She was admitted to a residential treatment center for treatment of her substance use. 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 Level IV; however, due to the enrollees scores in Dimension 3 and Dimension 4, Level V, Medically Monitored Residential Services, is needed for this enrollee.Final Result: The reviewer determined that the requested service was 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

A 40-year-old male enrollee requested authorization and coverage of continued treatment with the medication sporanox for the treatment of onychomycosis.  The Health Plan denied the enrollees request indicating that the requested treatment 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 medication is not medically necessary for treatment of the patients 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 cervical, thoracic and lumbar spine without contrast and magnetic resonance imaging (MRI) of the lumbar spine without contrast.The submitted documentation does not support that the requested services are medically necessary. In this case, the patient reports that she is in a great deal of discomfort, which she relates to her neck and back. Recent magnetic resonance imaging (MRI) studies demonstrated multilevel degenerative changes, with no acute abnormalities, and no evidence of a spinal stenosis. While recent MRI studies noted that axial lumbar sequences were not obtained, there were no disclaimers in the final Impression for the MRI. In common practice, if the lack of a part of a study impacts the final diagnosis or impression, specific note of that would be made in the Impression portion of the report. The final stated Impressions in the MRI studies, however, were clear and did not equivocate. There is no reason to repeat any part of the MRI at this time, especially after so short an interval. Therefore, magnetic resonance imaging (MRI) of the cervical, thoracic and lumbar spine without contrast is not medically necessary to treat the patients medical condition. In addition, magnetic resonance imaging (MRI) of the lumbar spine without contrast is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Euflexxa injections for treatment of the enrollees osteoarthritis. Findings: The physician reviewer found that the evidence based medical peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Bannuru and colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Pagnano and Westrich conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. In addition, Turajane and colleagues concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis which failed conservative treatment was found efficacious during a 54-month follow-up period. This has been found to be safe and effective and allow for delay of total knee replacement. In this case, the patient has been diagnosed with right knee tricompartmental osteoarthritis. She has undergone prior viscosupplementation series with documentation of six months pain reduction and the ability to avoid surgery. She has failed to respond to other conservative treatment including corticosteroid injections and activity modification. Therefore, the requested Euflexxa injections have been established as medically necessary for treatment of the patients right knee tricompartmental osteoarthritis.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

A 50-year-old female enrollee has requested Botox injections for the treatment of her chronic headaches and fibromyalgia. Findings:  Three physician reviewers found that although Botox is indicated in certain severe, frequent, refractory cases of migraine headache it should not be considered a first-line therapy for migraine headache.  There is ample literature demonstrating the benefit of prophylactic medications such as beta blockers, calcium channel blockers, amitriptyline, and antiepileptic medications (among others) for preventing migraine headaches. The literature provided demonstrates standard practice parameters (and the quality of literature supporting the use of each medication) for various age groups. These articles also reference additional literature regarding this subject. It is not clear that this patient could derive better or even adequate results from Botox.  Furthermore, the long-term safety and effect of Botox in a patient with medical problems such as this patient are not entirely clear.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested the medication Hysingla ER 40mg for medical treatment of her chronic pain.  Findings:  The physician reviewer found that this patient has been on chronic opioids without documentation of improved function or attempted weaning.  The records document non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound.  The current standard of care for chronic pain is treatment in a multidisciplinary pain management practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  Ballantyne and Mao reported that prolonged use of opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects.  The current medical evidence does not support the requested medication in this clinical setting.  All told, the requested Hysingla ER 40mg is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee has requested for Oxycontin for treatment of his chronic obstructive pulmonary disease (COPD) and degenerative disc disease (DDD).  Findings:  The physician reviewer found that the records do not document any medical indication for the patients present Oxycontin dosing. There are no imaging studies or documentation illustrating the severity of the patients DDD. The current standard of care for chronic pain is treatment in a multidisciplinary practice including physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. Opioids are considered adjunctive to this therapy with the maximum recommended dose for Oxycontin of 80mg twice per day as indicated for cancer pain (Fishman).
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the residential treatment center (RTC) services provided. Findings:  The physician reviewer found that the records do not support the medical necessity of the RTC services provided to this patient. The patients post-acute withdrawal symptoms were mild. He was not suicidal or homicidal, aggressive or violent. He was medically and psychiatrically stable. He was cooperative, compliant, and participated in his treatment. There were no emotional, behavioral, or cognitive issues that would have prevented him from stepping down to a less restrictive treatment setting. He was medically and psychiatrically stable and he had a safe and supportive environment at home. His emotional difficulties, cravings, and relapse education and prevention could have been dealt with in an ambulatory level of care in conjunction with community support system.  All told, the RTC services provided were not medically necessary for treatment of this patients behavioral health 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: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee has requested continuation of all or any of the skilled nursing facility (SNF) care services for treatment of his paraplegia after back pain and labile hypertension.  Findings:  The physician reviewer found that the patient has been in the inpatient rehabilitation setting for a prolonged period of time with back pain, urinary retention, decreased ambulation, and decreased ability to perform self care. As of the said date, he had plateaued with respect to function. Going forward, the patient would be expected to require a wheelchair for mobility, a wheelchair accessible residence to return to, and assistance with activities of daily living. However, the records do not support the likelihood of further significant gains with ongoing inpatient therapy interventions. Although the medical literature supports subacute rehabilitation in a variety of clinical settings, the medical literature does not support the necessity of this intervention in the absence of demonstrated and expected function progress (Chen, et al; Kortebein, et al). All told, continuation of the SNF care services provided from the date in question and forward is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee has requested for lung surgery for treatment of his metastatic lung cancer.    Findings:  The physician reviewer found that a lobectomy, or surgical excision of a lobe, is likely required in this case and remains a contraindication for surgical resection. In addition, this patient has evidence of advanced lymph node disease (hilar and mediastinal nodes demonstrated on PET scan), and in this situation, surgical therapy is not considered first-line therapy. Treatment with chemotherapy and consideration of radiation therapy is appropriate in this setting.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee has requested a rapid lysis procedure for the treatment of his blood clot. Findings:  The physician reviewer found that treatment with heparin and Coumadin are the standard of care for this circumstance.  There is no evidence that the requested procedure is necessary for the patient or that it is more clinically appropriate than treatment with heparin and Coumadin.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization program services. Findings:  The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS) is an accepted, national standard for determining the appropriate level of care for children and adolescents. In terms of risk of harm, the records support a score of 3. The patient has chronic passive suicidal ideation. She did not have any intent or plans to act on her suicidal thoughts. She has a history of self-injurious behavior. With regards to functional status, the records support a score of 2. The patient was making improvements in her functionality. She was attending her activities of daily living. In terms of comorbidity, the records support a score of 3. The patient has a comorbidity of anorexia nervosa. The patient did not have any orthostatic hypotension or other medical problems that required intensive monitoring. The patient continued to struggle with her body image. However, the patient was cooperating with treatment and had an ideal body weight ranging from 91-93% around the dates in question. With regards to environmental stress of the recovery environment, the records support a score 3. The patient continues to have interpersonal conflicts with her parents. In terms of environmental support, the records support a score of 2. The patients parents are supportive of the patient. With regards to resiliency, the records support a score of 2. The documentation reports that the patient made improvements. She was participating in treatment and was cooperative with staff. With regards to acceptance and engagement, the records support a score of 2. The patient was able to develop positive therapeutic relationships with clinicians. She was cooperative with treatment. Thus, the records support a composite score of 17. Based on these criteria, the patient meets criteria for intensive outpatient program level of care. The patient continued to need treatment for her anorexia nervosa and emotional dysregulation, but this could have been done in a less restrictive environment. Therefore, partial hospitalization program services were not and are not medically necessary for the treatment of this patient. 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 psychiatry with expertise 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: Medical Necessity
Decision: Overturned

A female enrollee requested residential mental health treatment center services for medical treatment of her behavioral health condition.  Findings:  The physician reviewer found that residential treatment services were medically necessary for treatment of the patients medical condition. This patient could not have been managed at a lower level of care. The services at issue were medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Keytruda. The Health Plan has denied this request indicating that the requested medication is considered investigational for treatment of the enrollee who has been diagnosed with cancer.Findings:  Ipilimumab, nivolumab, and Keytruda (pembrolizumab) are new monoclonal antibodies that bind with tumor antigens responsible for blocking immune attack from circulating lymphocytes. The latter two antibodies bind to programmed cell death protein 1 (PD-1) and the ipilimumab binds to CTLA-4. The Keynote-028 trial enrolled 24 patients with advanced endometrial cancer and pembrolizumab was found to be well tolerated in this heavily treated group of patients and showed some efficacy. Moreover, the U.S. Food and Drug Administration has approved pembrolizumab for metastatic solid tumors that have been identified as MSI-H, such as in this patients case. According to the current medical literature, Keytruda is likely to be of greater benefit for the treatment of this patients medical condition than the available standard therapies.  Final Result: Two of the three reviewers have determined the requested medication 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:  All three reviewers are board certified in in internal medicine with sub-specialty certification in medical oncology 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: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee requested Eylea injections for medical treatment of her diabetic macular edema.  Findings:  Two physician reviewers found that the Eylea injections were not and are not likely to be more effective for this patient than other available options. At the time of the patients treatment, there were two other treatment options available, bevacizumab (Avastin) and ranibizumab (Lucentis) intravitreal injections. Eylea is no more effective that Lucentis for a patient with good visual acuity. For this patient, Eylea and Lucentis would both be equally effective, and both are slightly superior to Avastin. In sum, there is a lack of evidence in the medical literature indicating that for patients with good visual acuity treatment with Eylea is likely to be more beneficial than any available standard therapy.