Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested RT300 Functional Electrical Stimulation (FES) Cycle Rehabilitation System for treatment of the enrollees tetraplegia. Findings: Two physician reviewers found that there is a lack of support for the requested device in this clinical setting.  There is a lack of proven significant health or functional benefit of exogenous neurostimulation therapy of paralyzed muscles using FES cycle ergometry.  There have been a number of small papers published over the years providing some preliminary data suggesting possible benefits, but larger studies designed to evaluate the actual clinical efficacy of passive exercise such as FES cycle ergometry in the setting of spinal cord injury have not been completed and published.  While repeated bouts of exogenous neurostimulation of paralyzed muscle may potentially reverse muscle atrophy in paralyzed muscle, there is a lack of significant health or functional benefit of this achievement in spinal cord injury because the muscle tissue that is gained or spared does not protect against pressure ulcers or provide other clinically or functionally relevant benefit.  It does not obviate the need for pressure relief.  To date, the limited data that are available provide mixed results regarding health measures.  There are insufficient data regarding clinically-relevant outcomes related to the use of this device on bone health after spinal cord injury.  Thus, the medical evidence has not established the superior efficacy of the requested RT300 FES Cycle Rehabilitation System for the treatment of this patient.Final Result: Two 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: All three physician reviewers are board certified in physical medicine and rehabilitation 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for endoscopic thoracic sympathectomy. Findings:  The physician reviewer found that the patient has not tried some standard medical treatments for hyperhidrosis including oral anticholinergic agents or Botox injections, but there is no reasonable expectation that these agents will have any significant or long-lasting benefit for this patient since he has already failed topical Drysol prescription grade aluminum chloride. The oral anticholinergic treatments will dry the entire body, and the patients mouth and eyes will likely dessicate long before any improvement is noted in the hands or axillae. In addition, Botox injections are U.S. Food and Drug Administration (FDA) approved for the axillae, but not the hands. Thoracoscopic sympathectomy is thus considered the treatment of choice for management of this patients massive palmar sweating. The curative effect is immediate and dramatic, immediately impacting the long-term quality of life for the patient. Furthermore, studies have confirmed that it is precisely in teenage years, rather than later in life, that the sympathectomy is most effective with the least compensatory hyperhidrosis side effects, likely because of the plasticity of the immature nervous system. All told, the requested endoscopic thoracic sympathectomy is supported as medically necessary for treatment of this patients massive palmar, axillary and plantar hyperhidrosis. Final Result: The reviewer determined that the requested surgery 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 thoracic 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: At issue in this case is whether the inpatient behavioral health services that were provided were medically necessary for the patients condition.  Upon admission, she reported hearing voices telling her to harm herself. Diagnoses include schizoaffective disorder. The progress notes indicate that the patient was open to discussion of her depression and anxiety symptoms. The patient did not exhibit any suicidal or homicidal ideation or signs of psychosis during the dates in questionThe Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults, to ensure their level of care meets their individual needs, safely and effectively, in the least restrictive setting possible. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. The composite score was 14, which is consistent with low intensity treatment services.Final Result: The reviewer determined that the requested services 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: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee has requested Tylenol with codeine for treatment of her pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this patients case.  The standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.  Medications with a high risk of dependence and tolerance, such as Tylenol with codeine, are not recommended.  The current medical literature does not support the requested medication in this clinical setting.  Baron and McDonald noted that high-dose and short-acting opiates may contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting condition.  Short-acting opiates with high-dose acetaminophen are more likely to cause adverse outcomes.  Ballantyne and Mao noted that prolonged use of high-dose and short-acting opiates might induce abnormal pain sensitivity.  All told, the requested Tylenol with codeine is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center for treatment of the enrollees behavioral health condition. Fulfills requirements of (1374.33) Findings:  The physician reviewer found that Based on the Level of Care Utilization System (LOCUS) criteria, the patient met criteria for treatment in a less restrictive environment. The patients risk of harm score is two (2), low risk of harm. The patient has no prior suicide attempts. The patient did not have any suicidal or homicidal ideation.  The patients functional status score is three (3), moderate impairment. The patient had a significant deterioration in his ability to fulfill responsibilities and obligations. The patients medical, addictive and psychiatric co-morbidity score is three (3), significant co-morbidity. The patient has a significant co-morbidity of alcohol use disorder, opiate use disorder, sedative hypnotic use disorder, and PTSD. The patient has no medical problems that would require 24-hour observation. The patients recovery environment score is two (2), mildly stressful environment. The patients spouse is supportive. The patients level of support score is two (2), supportive environment. The patient has a supportive spouse. The patients treatment history score is three (3), equivocal response to treatment and recovery. Previous treatment for substance use has been equivocal. The patient has continued to struggle with sobriety. The patient has a history of attending Alcoholic Anonymous (AA) meetings. The patients engagement and recovery status score is two (2), positive engagement and recovery. The patient is cooperative and compliant with treatment. The patient is highly motivated for sobriety. The patient participated in groups and activities. Based on these criteria, the patient has a total score of 17 and would meet criteria for an intensive outpatient program. The patient could have been provided in a less restrictive environment. Therefore, RTC level of care services provided 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 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 52-year-old female who underwent a matrixectomy of the right hallux toenail in December 2004. In early January 2005 she was seen in follow-up and placed on antibiotics. During the December 2004 visit she related experiencing right hallux pain for four months. In March 2006 she again reported right hallux toenail pain from an ingrown nail beginning approximately six months earlier. She reported that a pedicurist was not able to resolve the problem. At this visit she requested a right hallux matrixectomy. The Health Plan denied her request indicating the requested procedure is not medically necessary.The submitted clinical information demonstrates that this patient has had chronic painful ingrown toenails since well before December 2004. It is certainly medically appropriate to attempt to stop the recurrent ingrown toenail with a phenol matrixectomy procedure. It is not the standard of care to have a pedicurist treat/remove ingrown toenails. The procedure requested by the patient is medically appropriate and indicated and should be authorized. For the reasons set forth above, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old male enrollee has requested inpatient services for treatment of his bipolar disorder. Findings:  The physician reviewer found that the patient was noted to be suicidal on admission, but a detailed risk assessment is not documented.  There is no indication of a plan, intent or history of recent suicide attempts. Subsequent physician progress notes do not include risk assessments, and no further suicidal ideation or behavior is documented. The patient did not show evidence of psychosis, agitation, risk to others, need for intramuscular medications, restraints, seclusion or other behaviors or procedures which require skilled nursing observation, intervention and containment in a locked setting on a 24-hour basis. No serious withdrawal symptoms were documented, and there was no indication of acute intoxication or an impending serious withdrawal syndrome as evidenced by abnormal vital signs or elevated Clinical Institute Withdrawal Assessment scores. The data reviewed in sum failed to establish medical necessity for inpatient level of care.  All told, inpatient services were not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 22-month-old male enrollee has requested speech therapy for treatment of the enrollees delayed speech.  Findings:  The physician reviewer found that the most recent speech evaluation provided was performed when the patient was 18-months-old. Speech acquisition at this age is quite limited, with the anticipated utilization of approximately 10 words (Simms). With a scattering out to 15 months both in receptive and expressive language, the patient was still at the lower limits for normal speech development, particularly for a male. Thus, speech therapy is not medically necessary for this patient at this time. The article by Buschman, et al. recommends evaluation for late talkers at the age of two, as a substantial number of late talkers will be verbal by this age. There is no medical necessity for speech therapy in this patient, given the results of his test scores at 18 months. However, his language development should be retested at the age of two. If he continues to demonstrate significant speech delay at that time, further evaluation would be medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for  inpatient services. The records reviewed document that this patient sustained a moderate-to-severe traumatic brain injury on the basis of his presenting neurological examination and imaging findings. As a result of his injury, he required intensive care unit (ICU) monitoring, intravenous (IV) sedatives, and/or restraints in order to adequately observe and treat his condition and prevent him from causing harm to himself due to encephalopathy. The chart suggests that this level of care could only be de-escalated after three days of care when the patients mental status had sufficiently cleared. Moreover, the provider noted concern for diabetes insipidus due to high volumes of urine output, and this required careful work-up and evaluation. Based on the extent of the patients injuries, the services provided from the time of initial presentation for three days were medically necessary to evaluate and treat traumatic brain injury and any sequalae. However, by the fourth day of admission, the patient was allowed to be up and out of bed without bracing or spinal precautions, prior to obtaining upright x-rays. Although the provider noted that the patient was able to tolerate ambulating with moderate to minimal assistance, the provider indicated that the patient was unable to tolerate x-rays. The records suggest that the patient could have been assisted with being upright in order to obtain x-rays. All told, inpatient services for three days were medically necessary for treatment of this patient while the remainder of the inpatient services were not medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in neurological 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 52-year-old male enrollee requested authorization and coverage of the medication epogen for the treatment of myelodysplastic syndrome.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that the medication epogen is not likely to be more beneficial for treatment of the enrollees myelodysplastic syndrome than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla for treatment of the enrollees psoriasis. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. According to guidelines by the American academy of Dermatology, the Health Plans formulary alternatives that include Humira, Enbrel and methotrexate are recommended for patients with chronic plaque psoriasis who are candidates for systemic treatment. In this case, the Health Plans formulary alternatives are medically reasonable and appropriate for this patient. Given the lack of failure or contraindication to formulary alternatives, the request for Otezla has not been established as 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 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

Nature of Statutory Criteria/Case Summary: The enrollee has requested viscosupplementation with Hymovis injections of both knees. As noted in the medical literature, viscosupplementation with intraarticular hyaluronic acid provides a moderate symptomatic benefit to knee osteoarthritis patients without major safety concerns. Overall, there is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis. Further, the benefits of hyaluronic acid are long-lasting when compared to intraarticular corticosteroids. Researchers found evidence from clinical studies of repeat courses of intraarticular hyaluronic acid. Hymovis is a new generation hyaluronic acid with distinctive viscoelastic and rheological properties, which has been approved by the U.S. Food and Drug Administration (FDA) for treatment of osteoarthritis of the knees. Results from the studies confirm that Hymovis alleviates knee pain since the first treatment cycle. The patients treated with two cycles of intraarticular injections of Hymovis have a progressive pain reduction that is maintained up to one year after the treatment. Hymovis is effective and safe in symptomatic treatment of painful knee osteoarthritis. In light of the foregoing, the request for Hymovis injections of both knees is medically necessary for treatment of this patients osteoarthritis of the knees.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 intensity modulated radiation therapy (CPT code 77338, 77418, and 77301) for treatment of her stage I Hodgkins lymphoma.  Findings:  Two physician reviewers found that based on the available documentation, the requested IMRT is not likely to be more beneficial for treatment of this patients stage I Hodgkins lymphoma than conventional therapy consisting of 3D conformal radiation. Although the National Comprehensive Cancer Network (NCCN) guidelines support the possible use of IMRT in certain clinical scenarios, it cannot be concluded that IMRT is superior to standard radiation techniques for all types of tumors (Filippi, et al). As in this patients case, supradiaphragmatic Hodgkins lymphoma would require an increased dose with IMRT to the breasts and lungs (Fiandra, et al; DeSanctis, et al). Thus, there is an increased risk for secondary malignancies. For these reasons, the requested IMRT (CPT codes 77338, 77418, and 77301) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcatheter aortic valve replacement (TAVR) for treatment of the enrollee, who is status post aortic valve replacement. Findings:  2/3 of the physician reviewers found that the physician reviewer found this patient has had rather rapid deterioration of his porcine aortic prosthesis with severe aortic regurgitation and increasingly severe symptoms of heart failure and atrial arrhythmias. He has a clear indication for repeat valve replacement of his failing prosthesis due to symptomatic severe aortic insufficiency. He also has significant underlying lung disease, which places him at higher risk for a repeat open valve surgery operation. Catheter based TAVR for a failing aortic prosthesis is a medically appropriate option for this patient based on recent trial data and guidelines. Therefore, the requested TAVR is likely to be more effective than other treatment options. Final Result: 2/3 of the reviewers determined that the requested services are 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 reviewer number one is board certified in internal medicine with sub-specialty certification in cardiovascular 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in cardiovascular 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in cardiovascular 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.