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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization services. The submitted documentation supports the medical necessity of the services at issue. This patient reported an early age of first use. His alcohol use was complicated by a history of cancer and co-occurring depression and anxiety.  This is of particular relevance since it has been well-established that anxiety-ridden mood disorders, without the complication of addictive illness, are difficult to treat and in general have poorer outcomes.  Notwithstanding, the patients alcohol use and psychiatric symptoms were impairing his daily routine and contributing to significant impairment across multiple domains of functionality. He was drinking a 12-pack or more on a daily basis. He had history of withdrawal symptoms.  He did not have a living environment conducive to recovery as he was living with his son who used cannabis regularly, which was a trigger for the patient.  On the first disputed date, the patient had no aftercare in place at the time. That day, the patient was anxious and not sleeping well. The next day, the patient still had trouble sleeping. On the following day, the nursing staff reported that the patient was agitated and worried, with craving and mild withdrawal symptoms. The psychiatrist noted anxiety and mild withdrawal and elected to add a new medication, gabapentin, to his therapy.  The record reflects that the treatment during the dates of service at issue focused on aftercare planning and treatment consolidation with the application of complex pharmacotherapy and core elements of recovery-oriented interventions and therapies. Considering the severity of this patients illness, the services at issue were medically appropriate. In sum, the services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards and facilitated transition to a less restrictive setting. Additionally, the services provided at the time were reasonably expected to improve his condition and prevent a more serious episode of illness. All told, partial hospitalization services were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for OxyContin and oxycodone. In the documentation available for review, this patient presented with postsurgical pain. However, the records document that the patient was on several medications prior to surgery that were continued in the postoperative period that were not opioids. In addition, not all non-opioid treatment options were utilized to the highest effective dose. Specifically, gabapentin is not the highest effective dose of this medication. Moreover, it is reasonable to consider alternatives to opioids. The current evidence based research does not support primarily opioid focused therapy as treatment for shingles. Furthermore, no objective treatment goals for pain and function are noted for the medications at issue. For these reasons, the OxyContin and the oxycodone were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the medications 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 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

This is a 53-year-old female who has requested authorization and coverage for breast reduction surgery. Her weight on 7/2/04 was 269 pounds. She was seen in January 2003 and her weight was 219 pounds. In 1990 her weight was 285 pounds. At that time, she was wearing a 46DD bra. Her current reported bra size is 48DD. She complains of chronic neck, shoulder and interscapular back pain, tension headaches, inframammary rashes and significant hand paresthesias with the right being worse than the left in the ulnar nerve distribution. She has had a mammogram within the last year and has no nipple discharge or lumps. The patient relates she gained weight from 2003 to 2004 secondary to depression for which she is being treated. She was not on a weight loss program at the time of her 7/2/04 visit but does exercise by walking, swimming and going to the gym 3 to 4 times per week. Her physical exam on her 7/2/04 visit states, morbidly obese woman with massively enlarged, ptotic breasts, striae shoulder grooving is severe, and the shoulder posture is rounded. There is a very mild inframammary rash on the right and severe subaxillary rolls. The patient is seeking breast reduction surgery. Based upon the information provided, over the past 14 years the patients weight has fluctuated from a high of 285 pounds to a low of 219 pounds. Currently the patient is listed as 55 weighing 269 pounds with a body mass index of 44. The patient is morbidly obese. There is potential that through weight loss the patients bra size will decrease and issues related to her breasts will dissipate. If the patient is able to lose weight and sustain the weight loss and she continues to have issues related to her breasts surgery may be indicated; however, surgery is not indicated at this time.In addition to the above, there is neither documentation nor mention of intertrigo and its treatment in the patients records. Furthermore, there is no evidence of etiology of her ulnar nerve distribution arm numbness even though the patient has been seen by the neurology service on numerous occasions. Based upon the information set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 34-year-old transgender female who was diagnosed with gender dysphoria. The patients provider noted the patient had symptoms of chronic anxiety and depression due to her body not aligning with her identity. The records noted that the patient was being treated with hormone therapy. The patient has requested authorization and coverage for any or all facial feminization surgeries. At issue in this patients case is whether any or all facial feminization surgeries are medically necessary for treatment of the patients medical condition. The current medical evidence supports the requested services in this clinical setting. In this case, the records document gender dysphoria. Researchers reported that surgical treatment of transgender patients is associated with improved mental health-related quality of life. The World Professional Association of Transgender Health states that facial feminization surgery and reconstructive procedures are medically necessary for the treatment of gender dysphoria. Therefore, any or all facial feminization surgeries 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 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 intensive outpatient program (IOP) services for treatment of the enrollees behavioral health condition.  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue. According to the documentation submitted for review, the patient was not at risk for withdrawals as his last use was three months prior. He was medically and psychiatrically stable on his medications. Although he had experienced psychotic symptoms in the past, he did not show evidence of psychosis. He denied suicidality or homicidality. He was not aggressive. He was physically and cognitively able to provide for his activities of daily living and continue in treatment. He verbalized his desire and his knowledge of triggers and negative consequences of substance use. He was aware of his risk of relapse. He lived with his mother and had her support. He had transitioned from a wilderness program, from which he had improved. It was unlikely that the structured setting of IOP would provide significant further improvement. The patient did not meet medical necessity criteria for IOP and could have been safely and effectively managed at a lower level of care. Thus, the services at issue were not and are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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 forty-five year-old female who has undergone cosmetic breast augmentation surgery is requesting authorization and coverage for the medication Accolate to prevent recurrent capsular contraction.Reviewers Findings:  The reviewing physician found that Accolate is not FDA approved for the treatment of capsular contracture and is not necessary to maintain or improve the patients health.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Taltz 80 mg/mL autoinjectors. The America College of Rheumatology (ACR) recently released guidelines on the treatment of psoriatic arthritis. The ACR noted that for patients with active psoriatic arthritis despite treatment with a tumor-necrosis factor inhibitor (TNFi) biologic monotherapy, switching to a different TNFi biologic monotherapy is recommended over treatment with Taltz, which is an IL-17 biologic (Singh, et al.). In this case, the guidelines support treatment with a second TNFi. This patient has failed treatment with Enbrel, Cosentyx, sulfasalazine, leflunomide, and methotrexate due to intolerable side effects or lack of efficacy. She experienced a partial response to a TNFi in her joints and there is no contraindication to a trial of a second TNFi. Based on current data, Humira, Cimzia, and Otezla are supported as safe and effective for the treatment of psoriatic arthritis and the patients medical records do not report a contraindication to these agents. All told, the requested Taltz 80 mg/mL autoinjectors are not medically necessary for treatment of this patient.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 internal medicine with subspecialty certifications in allergy and  immunology and rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a ten-year-old male enrollee has requested growth hormone therapy (Nutropin AQ) for the treatment of the enrollees short stature, poor growth velocity and growth hormone deficiency. Findings:  The physician reviewer found that this patient has delayed pubertal development but will not nearly attain his genetic height potential. However, his adult height prediction exceeds the cut-off level recommended by the FDA in July 2003 for growth hormone therapy for idiopathic short stature. Thus, growth hormone therapy cannot be recommended as medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for morphine 100 mg every six hours for treatment of the enrollees medical condition.Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The use of opiates for fibromyalgia is not supported by the current medical evidence.  Per the medical literature, the use of high-dose morphine may lead to a paradoxical state of increased pain sensitivity, opiate-induced hyperalgesia.  There are alternative, U.S. Food and Drug (FDA) approved medications which have strong statistical evidence backing their use.  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 physician 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Aimovig. Findings:  The physician reviewer found that the current guidance from the American Headache Society (AHS) indicates that prior to the introduction of calcitonin gene-related peptide (CGRP) antibody agents in chronic migraine, established prophylactic therapies should be used. There are a large number of well-established prophylactic therapies for migraine headaches that have substantial support in the medical literature. In this case, the patient has been treated with topiramate and amitriptyline for chronic migraine headaches. While there are concerns about the choice of other prophylactic agents given her comorbid diagnosis of bipolar disorder, there are other level A or B treatments that have greater support in the clinical literature than Aimovig. Given these findings, the requested Aimovig is not supported as medically necessary for treatment of this patients chronic migraines. 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 neurology with subspecialty certification in sleep medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication, Korlym. The enrollee has obesity, uncontrolled diabetes and hypertension. Their blood sugar became difficult to manage with the medication regimen and the endocrinologist suspected they might have hypothyroidism or Cushings syndrome. A follow-up thyroid function test (blood work) and a standard 1mg dexamethasone suppression test were ordered. While the enrollees thyroid function test resulted in normal values, the enrollee was found to have mildly suppressed cortisol and ACTH levels. The physician indicated the enrollee's dexamethasone suppression test was positive and a CT scan of the adrenal gland was to be performed to see if the enrollee had a tumor; if not, the enrollee was to be put on Korlym. Notes indicate the enrollee was taking Jardiance, Trajenta and Fenofibrate medications.  The CT scan was negative and Korlym, medication, was prescribed. Korlym is an approved glucocorticoid receptor (GR2) antagonist used to treat adults with Cushings syndrome with concurrent hyperglycemia who have failed surgery, or are not surgical candidates. In addition to improvement in glucose metabolism, Korlym has been shown to decrease body weight and improve quality of life. Clinically, the enrollees morning cortisol levels are consistent with Cushings syndrome. However, there is a false positive rate of 20%, which improves to 5% if the cut-off is increased. This explains the need for a second test to improve the accuracy of the diagnosis. Guidelines indicate that due to the rarity of Cushings syndrome, the high prevalence of conditions, such as diabetes mellitus and obesity, and the limitations of the screening tests, the risk of false-positive test results is high. False-positive results are reduced if case detection is limited to individuals with an increased pretest probability of having the disorder, such as this enrollee. The testing strategy places higher value on reducing the number of false-positive test results, particularly in enrollees with very mild disease in whom the benefits of intervention are unproven. This enrollee has a level suggestive of, but not diagnostic of, Cushings syndrome because there is no evidence in the record of a confirmatory second test prior to her diagnosis of Cushings syndrome.  Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in endocrinology, diabetes and metabolism 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: The patient has requested authorization and coverage for epidural steroid injection Current evidence based medical literature supports the use of epidural steroid injections as an effective treatment for radicular pain due to disc herniation. However, there is a lack of high-quality evidence demonstrating the effectiveness of epidural steroid injections for the treatment of radicular pain due to spinal stenosis. Additionally, there is a paucity of literature regarding repeat transforaminal epidural steroid injections. Murthy and colleagues concluded that most patients do not require repeat transforaminal epidural steroid injections for the treatment for lumbar radicular pain. This patient presents with complaints of severe low back pain and functional limitations. The medical records indicate that he has a history of low back pain radiating down the left lower extremity. Clinical examination findings document a positive straight leg raise on the left but no evidence of any focal neurologic deficit. He has undergone routinely scheduled lumbar epidural steroid injections over at least the past year. In this case, the patient experienced at least 50% pain relief and functional improvement following two injections. There is no clinical documentation of benefit in pain or function associated with the last injection. There is a lack of supporting medical evidence to support the safety and effectiveness of ongoing routine epidural steroid injections for the treatment of radicular low back pain. The records do not document any evidence of a lumbar spinal pathology such as disc herniation, to support a clinical indication for an epidural steroid injection. For these reasons, the requested epidural steroid injection is not medically necessary for treatment of 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A  enrollee has requested authorization and coverage for traditional acupuncture with electrostimulation. Review of the submitted documentation supports the medical necessity of the requested services. The provider has recommended traditional acupuncture with electrostimulation for treatment of the patients laryngeal spasm and dysphonia. Based upon the documentation provided, this appears to be an initial trial of acupuncture for this patient. Review of the relevant peer-reviewed evidence reveals patients who received acupuncture reported improvements in voice production` in this setting. The patients provider noted that Botox injections would be challenging in this patients case. Studies show that the requested therapy is `comparable to the results achieved with botulinum toxin injection. Consequently, as the patient is significantly symptomatic, a trial of acupuncture with electrostimulation is clinically appropriate and medically necessary.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 oriental medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.