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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) Adderall and (2) Ativan. The U.S. Food and Drug Administration (FDA) approves the use of Adderall for the treatment of attention deficit hyperactivity disorder (ADHD). The FDA notes that contraindications to Adderall include agitated states. In this case, while the patient reports problems with attention and concentration that they attributes to ADHD, these issues may be caused by a variety of mental health disorders, including major depressive disorder, bipolar disorder, generalized anxiety disorder, obsessive compulsive disorder, learning disorder(s), and various substance use disorders, or may be caused by general medical conditions, including hypothyroidism, hypoglycemia, sleep disorders, hearing and vision impairment, and seizure disorders. Further, comorbidities such as depression, PTSD, various anxiety disorders, and personality disorders may complicate an ADHD evaluation. Given that the patient has been seen by several providers and has undergone psychological screening without a diagnosis of ADHD, the requested (1) Adderall is not medically indicated. Lorazepam (brand name Ativan) is a medication in the benzodiazepine family. Kennedy and ORiordan note that while benzodiazepines have effective anti-anxiety properties, best practice guidelines generally recommend short-term use, for two to four weeks, at the lowest possible dose due to issues of tolerance and dependence. The authors further note that benzodiazepines should only be prescribed in the lowest effective dose for the short-term relief of severe anxiety or panic disorder, usually in an acute crisis situation. In this case, the patient was prescribed lorazepam upon presenting to the urgent care. While the urgent care providers prescription of lorazepam may have been medically necessary for the acute treatment of this patients anxiety at that time, given that current medical literature does not support the prescribing of benzodiazepines beyond the short-term use, the requested (2) Ativan is not medically indicated. Therefore, (1) Adderall and (2) Ativan are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medications 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 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 fentanyl 100 mcg/hour every 72 hours, Dilaudid 8 mg and Flexeril 10 mg; or in the alternative fentanyl 100 mcg/hour every 72 hours, Norco 10 mg and Flexeril 10 mg for treatment of her back, knee and hip pain. Findings:  The physician reviewer found that based on the medical literature and in consideration of the presented clinical records, the request for fentanyl 100 mcg/hour every 72 hours, Dilaudid 8 mg and Flexeril 10 mg; or in the alternative fentanyl 100 mcg/hour every 72 hours, Norco 10 mg and Flexeril 10 mg are not medically necessary for treatment of the patients medical condition. The documentation submitted for review fails to demonstrate a current reconciliation of the patients medications and an adequate evaluation of her pain condition. In addition, the requested dose of Fentanyl is in excess of that which should be recommended for a non-opioid tolerant patient and places the patient at an increased risk for adverse side effects including life threatening respiratory depression. Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in physical medicine and rehabilitation 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for digital breast tomosynthesis (3D mammogram).The main weakness of mammography is the detection of cancer in women with radiographic dense breasts. While nearly all cancers will be apparent in fatty breasts, only half will be visible in extremely dense breasts. This is a result of the masking or camouflaging of non-calcified cancers by surrounding dense tissue. An advantage of tomosynthesis is better delineation and characterization of breast masses. The primary benefit of digital breast tomosynthesis would be expected to be for non-calcified mammographic findings, such as masses, asymmetries, and distortion. In the most basic application, digital breast tomosynthesis would allow visualization of cancers not apparent by conventional mammography, thus improving sensitivity. Kopans and colleagues found that the clarity with which calcifications were seen on digital breast tomosynthesis was equal to or better than conventional mammography. Further, Skaane and colleagues found that the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Similarly, Rafferty and colleagues stated that the addition of tomosynthesis to digital mammography offers the dual benefit of significantly increased diagnostic accuracy and significantly reduced recall rates for non-cancer cases.In this case, the patient has known heterogeneously dense breasts. Patients with dense breasts benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, digital breast tomosynthesis (3D mammogram) is medically necessary for the evaluation of the patients medical condition.Final Result: The reviewer determined that the requested service is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.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 partial hospitalization program (PHP) services for treatment of the enrollees eating disorder.  Findings: The physician reviewer found that the medical records provided for review demonstrated that safe and effective care could not have been reasonably provided in a less restrictive setting than PHP and these services remain medically necessary. The patient is obese with a body mass index (BMI) of 43. The patients nearly lifelong pathological eating habits and subsequent obesity negatively impacts her sense of self and physical health. Additionally, she has significant co-occurring psychiatric illness. The patient has made modest progress but has been unable to consolidate meaningful treatment gains thus far during the admission. The provider described the patient as self-critical. The patient was anxious at meal time and taking small bites and with long pauses. The patient was not motivated to eat at home due to not having any consequences and she reportedly binged that night. The following day she was hopeless and suicidal. The services are evidence-based and aimed at optimizing the skills needed to succeed in a less restrictive treatment setting. Further, the services are reasonably expected to improve the patients condition and prevent a more serious episode of illness. Review of the clinical documentation, in context of the relevant peer-reviewed medical literature shows the PHP services were and are medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the services at issue were and 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for linezolid and/or omadacycline (Nuzyra). This patient presents with multiple lung nodules and a diagnosis of M. chelonae on sputum culture. Her provider has recommended treatment with a regimen of linezolid and Nuzyra. As noted in the medical literature, atypical mycobacteria infections are difficult to treat. The regimen ordered for this patient is appropriate since Nuzyra has been shown to be active against M. abscessus, which is a closely related organism to M. chelonae. In addition, the recommended regimen consisting of linezolid will avoid the potential toxicities associated with long-term use of aminoglycoside antibiotics (Pecho-Silva and Navarro-Solsol). Therefore, the requested linezolid and Nuzyra are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medications 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 internal medicine with subspecialty certification in infectious disease 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 OxyContin 20 mg tablet extended release 12 hour for treatment of the enrollees back pain. Findings:  The physician reviewer found that The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative and the non-palliative setting. However, in the documentation available for review, no objective treatment goals for pain and function were noted for the requested medication. The Centers for Disease Control and Prevention (CDC) states that when starting opioid therapy for chronic pain, clinicians should prescribe immediate release opioids instead of extended release/long acting (ER/LA) opioids. The CDC also states when opioids are started, clinicians should prescribe the lowest effective dosage. The CDC states regarding co-prescription of opioids with benzodiazepines, epidemiologic studies suggest that concurrent use of benzodiazepines and opioids might put patients at greater risk for potentially fatal overdose. The CDC also states clinicians should avoid prescribing opioids and benzodiazepines concurrently whenever possible. In this patients case, a treatment plan was not provided including a plan to taper down opioid use. The records do not provide medical evidence based rationale by the provider for the increase in the medication. There was no indication that long term consequences with the continual increase in opioids were discussed. Risk and benefit analysis must be performed to justify the requested level of 90 morphine milligram equivalents (MME) per day. Also, it is clear that tolerance has taken place since the start of the narcotics, as just a few months ago 60 MME/day was sufficient and 45 MME/day before that. Dose escalation is not a long term plan but a short term plan for the treatment of tolerance. There is also the possibility, in this case, of opioid induced hyperalgesia. The provider did not indicate a clear objective goal for this high opioid dose. The medical literature states that prior to increases in medication dosage, all other non-pharmacological ways of taking care of the pain should be addressed. In this patients case, there does not appear to be a completion of behavior therapy despite much research to support its use. Finally, not all non-opioid medications have been optimized or tried.  For all these reasons, OxyContin, 20 mg tablet ER, is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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.
Appeal type: Medical Necessity
Decision: Upheld

A 66-year-old female enrollee requested authorization and coverage of a smaller oxygen conserving devise (M6 Tank) due to her COPD, osteoporosis, partial permanent disability of the left wrist, and a fractured right knee.  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 equipment is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 49-year-old male with a diagnosis of schizoaffective disorder who was admitted to a partial hospital program (PHP). He presented for admission to PHP with a one-month history of increased auditory hallucinations, confusion, and self-destructive thoughts. He also had increased paranoid delusions and generalized disorganization in his thinking. His medications included Clozaril, Risperdal, Seroquel, lithium, Effexor-XR and Zoloft. By December 2005 the patient had stabilized to his previous level of functioning.  The patients wife requested reimbursement for services provided after December 2005 and on-going PHP authorization.  The Health Plan denied this request based upon a determination that the services were not medically necessary after December 2005.A review of the record demonstrates that the patient was neither suicidal nor homicidal during the time he was in the PHP. By December 2005 his psychosis had decreased and he was stable. There were no adjustments made to his medication regimen.  He could have been managed in an outpatient treatment program with medication management on an as necessary basis. I agree that by December 2005 he had derived the maximum benefit possible from the PHP and there was no reasonable expectation of improvement. Therefore, I have determined the services at issue were/are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old female enrollee has requested two phase lymph preparation and drainage therapy device (Flexitouch system) for treatment of her lymphedema. Findings: The physician reviewer found that lymphedema management is highly individualized and should be designed to meet the needs of the particular patient (Warren, et al). Device selection is critical to the success of home based lymphedema therapy and should take into account the mechanism of action and functionality of the device (Mayrovitz). In the case under review, the patient has failed a full spectrum of conservative management techniques including trial of a standard lymphedema pump. By contrast, she experienced a good clinical response to the prescribed therapy with the Flexitouch. Programmable devices that provide truncal and proximal clearance are highly desirable for an effective home program (Mayrovitz). Consistent with these findings, the requested Flexitouch system is medically necessary for treatment of this patients condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for autonomic testing. Findings:  Three physician reviewers found that there are multiple methods of diagnosing POTS including the use of tilt table testing. There are sufficient diagnostic criteria established for tilt table testing that it can be considered a useful method of diagnosis. Further, autonomic testing has been demonstrated to be useful in the diagnosis of POTS as a thorough evaluation of the autonomic nervous system. In addition, the use of transcranial Doppler may help establish whether the patients cerebral blood flow has been compromised. All told, the current peer-reviewed medical literature supports the requested autonomic testing as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2 of 3 reviewers determined that the requested testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in neurology 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 61-year-old female enrollee has requested continued acupuncture treatment for treatment of her low back and hip pain. Findings:  The physician reviewer found that acupuncture can be very effective in the management of chronic low back pain.  Patients who respond well to an initial course of treatment remain at risk of a recurrence of the pain. In those individuals, a repeat course of acupuncture is clinically indicated. In this patients case, she has chronic low back pain that was resistant to most interventions. She has tried physical therapy and chiropractic care, with no improvement.  Per a note from the treating physician, the patient benefitted from prior acupuncture services provided. A few weeks later, the patient reported limited ability to work due to continued pain, and she noted that acupuncture treatment aids in alleviating her pain. Thus, continued acupuncture services were and are medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for cataract surgery. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients cataracts. The submitted documentation does not support the medical necessity of the requested services. At issue in this case is whether cataract surgery is medically necessary to improve the patients vision and functioning. Although the patient exhibits cataract on examination, the records show that vision loss is primarily related to an uncorrected refractive error. The patients symptoms are likely correctable with glasses.  The provider prescribed glasses to improve the patients vision and functioning. However, it appears that the patient wishes better vision without glasses. There is not compelling evidence that the patients cataract is causing any of the patients symptoms. Therefore, the requested services are not medically necessary for the treatment 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 ophthalmology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested a positron emission tomography (PET) scan for evaluation of her ovarian cancer. Findings:  Three physician reviewers found that the current medical evidence supports the requested services in this patients case.  The patient has had sequential PET/CT scans, and it is easier to compare the same imaging modality as opposed to starting with a different cross-sectional examination.  There are other advantages to PET as well.  PET/CT scans image the entire body, as opposed to CT scans.  To perform a comprehensive CT scan for this patient, one would need to do a CT scan of her neck, chest, abdomen, and pelvis.  A PET/CT scan would image all of these areas as well as her skeleton and spine.  In addition, PET offers the advantage of imaging activity of the tumor.  On occasion, especially with regards to lymphoma, a CT scan will demonstrate residual enlarged lymph nodes, but a PET scan will show that these nodes are not fluorodeoxyglucose (FDG) avid.  This patient was started on a new therapy, and it is important to assess whether there has been a therapeutic response.  Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewer 1, 2, and 3 are board certified in diagnostic radiology 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.