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

The patient is a 37-year-old female who had a body mass index (BMI) of 53 when evaluated for bariatric surgery. Her comorbid conditions included dyspnea on exertion, degenerative joint disease, fatty liver and lower extremity edema. The patients provider indicates her BMI had decreased to 49.5 and she has completed psychological and nutritional evaluations and was deemed an appropriate candidate for weight loss surgery. The psychological evaluation was absent from the record. The patient has selected the Lap Band procedure because she believes it is less invasive than other alternatives for surgical weight loss.  The Health Plan has denied coverage for the Lap Band based upon their determination that it is not medically necessary for treatment of the patients morbid obesity.With a BMI of approximately 50 and comorbid conditions such as dyspnea on exertion, degenerative joint disease, (DJD) fatty liver and lower extremity edema, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. However, the current scientific data clearly shows that the Lap Band is inferior to other surgical alternatives in terms of excess body weight loss. The weight loss with the Lap Band is typically 50% of excess, as compared to 60-70% with Roux-en-Y and greater than 60% with the duodenal switch. A patient who weighted 315 pounds would need to lose approximately 155 pounds to reach a BMI close to 25 for the surgery to be considered successful. If in fact the Lap Band procedure results in the loss of 50% of excess body weight, the patients BMI would remain at approximately 40, which is still considered morbidly obese.  Given the above information, the patient should investigate other surgical weight loss procedures to secure optimal weight loss. Additionally, the results of the psychological evaluation should be made available for review, to fully consider the patients appropriateness for bariatric surgery.Based upon the information set forth above, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 59-year-old female requested coverage for PET imaging with CT skull-thigh and PET imaging with CT full body and A9580 sodium fluoride F-18 for evaluation of the enrollee, who has a history of intraductal carcinoma of the breast. Findings:  Two physician reviewers found that the patient has a history of breast cancer.  She was noted to have increasing levels of the tumor marker CA 15-3.  Per the submitted documentation, a standard bone scan showed equivocal findings in the lumbar spine.  An MRI of the lumbar spine also showed equivocal findings in the L3 vertebral body.  The patient has requested coverage for PET imaging with CT skull-thigh and PET imaging with CT full body and A9580 sodium fluoride F-18.  In this patients case, the requested diagnostic procedures are likely to be superior over other methods of evaluation.  The medical literature has shown that the use of sodium fluoride F-18 is more sensitive for skeletal metastases than conventional radionuclide bone scanning, which are technetium based.  In this patients case, standard bone scan showed possible activity in the lumbar spine, and follow-up MRI showed equivocal findings.  Thus, conventional testing has yielded equivocal results, and the patients tumor marker continues to rise.  Therefore, PET imaging with CT skull-thigh and PET imaging with CT full body and A9580 sodium fluoride F-18 are likely to be of greater benefit than other modalities for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee has requested spinal fusion surgery (L4-L5 and L5-S1) for treatment of his low back pain.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested procedure. The patient has chronic low back pain and he has had residual symptoms/signs from his more recent laminectomy/discectomy. His most recent MRI does not show a recurrent disc herniation but does show the expected post-operative scar/granulation tissue. According to Bambakidis and colleagues indications for surgical fusion include instability, spondylolisthesis at the indicated segment, scoliosis, infection, tumor, fracture and spinal stenosis (Bambakidis et al). In this patients case, he does not have any of the accepted criteria listed above. Thus, the requested procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Urgent Care
Decision: Upheld

A 60-year-old male enrollee has requested services he received for evaluation of his medical condition. Findings:  The physician reviewer found that review of the submitted clinical documentation fails to demonstrate that a prudent layperson would have sought immediate medical attention on the date in question. Based upon the documentation provided, the patients symptoms were not of sufficient severity to lead a prudent layperson to believe that he or she required treatment on an emergent basis. In this patients case, he chose to pursue treatment with high intensity focused ultrasound treatment using Sonablate 500 in lieu of treatment options available. While the patient may have believed that treatment using Sonablate 500 was the most appropriate option for treatment of his condition, there is no evidence demonstrating that this treatment had to be performed on an emergency basis. The patient was not at risk of serious harm or decompensation if the services at issue had not been performed on an immediate basis. There is no evidence that the patient was experiencing significant symptomatology such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. All told, the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 40-year-old male who underwent anterior cruciate ligament (ACL) reconstruction for a left ACL tear and medial collateral ligament sprain in November 2005. He was examined by his orthopedist in May 2006. At that time it was noted the patient had full range of motion, but some residual ligamentous laxity and significant muscle atrophy and weakness. The patients orthopedist has recommended a custom brace for use with activity to help stabilize the knee. The Health Plan has denied coverage for the requested equipment on the basis that it is not medically necessary.The submitted clinical evidence documents the presence of residual ligament instability and muscle atrophy and weakness. Use of a brace for activity is medically indicated and necessary in this setting to protect the knee from further injury in its weakened condition. Ligament instability cannot be treated by rehabilitation or any other conservative therapeutic measures. Chronic, symptomatic ligament instability is an absolute indication for use of a brace to provide external stabilization.For the reasons set forth above, I have determined the requested equipment is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old male enrollee requested authorization and coverage of a referral for continued care from a pain management clinic. The Health Plan denied the request indicating that the requested referral is not medically necessary for treatment of the enrollees migraine headaches.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested referral is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested juvenile cartilage transplant into the talar dome for medical treatment of her osteochondral lesion. Findings:  Three physician reviewers found that there is a lack of quality studies supporting the use of juvenile cartilage transplant into the ankle. Overall, the use of juvenile cartilage transplant into the talar dome was not likely to be more beneficial than conservative treatments including non-steroidal anti-inflammatory drugs (NSAIDs), adaptive shoes, activity modification, appropriate low-impact exercise, or autologous chondrocyte transfer or osteochondral allograft transportation.
Appeal type: Experimental/Investigational
Decision: Upheld

A 66-year-old female has requested approval for minimally invasive lumbar decompression for treatment of her back pain and bilateral lower extremity pain.   Findings:  Three physician reviewers found that the patient has a history of bilateral low back, buttock, and leg pain.  The pain increases with activity and decreases with rest.  She has tried multiple medications, physical therapy, and a TENS unit, without lasting relief.  A lumbar spine MRI, three years ago demonstrated moderate to severe central spinal canal stenosis at the L4-5 level with ligamentum flavum hypertrophy.  The requested procedure is not likely to be superior over other available treatment options.  Chopko and Caraway reported on 78 patients who had undergone the minimally invasive lumbar decompression procedure.  Six week follow-up was obtained on 75 patients, and outcomes were generally favorable.  However, this follow-up period is too short to draw any conclusions from this study.  Mekhail and colleagues reported on 58 patients who underwent the minimally invasive lumbar decompression procedure.  One-year data showed significant reduction of pain and improvement in physical functionality, mobility, and disability.   However, this was not a controlled or randomized trial comparing minimally invasive lumbar decompression to other procedures such as standard laminectomy.  Also, the one-year follow-up period is not long enough to determine the efficacy of this procedure.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Euflexxa injections for treatment of the enrollees knee pain. Findings:  Two physician reviewers found that current evidence based medical literature states that hyaluronic acid injections in the knee are recommended for patients with severe osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including aspiration and injection of intra-articular steroids. Hyaluronic acid injections are not recommended for any other indications such as chondromalacia patella or patellofemoral syndrome. The effectiveness of hyaluronic acid injections for these indications has not been established. Peer-reviewed literature generally supports the use of hyaluronic acid injections for chronic moderate symptomatic osteoarthritis of the knee but states that application in sports related chondropathy has yet to be fully assessed. The ideal indication in the knee seems to be moderate femorotibial osteoarthritis without swelling. This patient was diagnosed with bilateral patellofemoral chondromalacia. A series of three Euflexxa injections were recommended and performed. Evidence based medical literature does not support the use of hyaluronic acid injections such as Euflexxa for the treatment of chondromalacia patella, as the effectiveness has not been established. There is a lack of compelling evidence presented to support these injections. Therefore, the Euflexxa injections were not likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were 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: Reviewers 1, 2 and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement for residential treatment center (RTC) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Applying the LOCUS criteria, this patient met the requirements for RTC services. The patient was at serious risk of harm given his excessive substance use with loss of self-control and self-harming behaviors. The patient demonstrated the inability to care for himself or remain safe as evidenced by instances of wandering naked in a public park. The patient exhibited serious functional impairment with ongoing impulsivity due to severe cannabis use and a psychotic disorder even while he was in the hospital environment. He had been unable to function in his home or college environments due to his psychosis and cannabis addiction. The patient was noted to have significant comorbidities with ongoing cannabis usage despite multiple detrimental effects, including the development of a psychosis that led to his inability to complete college or to live with his parents. The patients recovery environment was highly stressful, as he was unable to live with his parents and at the time of admission, was living in a tent surrounded by people who were using substances. The patients recovery environment provided limited support. The patients parents were his main supports, but they were unable to fully participate in treatment and make the necessary changes. The patient had previously shown moderate response to treatment but was unable to maintain recovery. At the time of discharge, he was not at baseline and continued to express ambivalence about taking psychotropic medications. The patient was minimally engaged in treatment, as he expressed little desire to change his previous behaviors or lifestyle. He had difficulty accepting the reality of his underlying psychiatric illness and the role that cannabis played in exacerbating his condition. The patients composite score is 25, which is consistent with medically monitored residence-based services. Given this support, the RTC services were medically necessary for 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

A 60-year-old male has requested OxyContin 40mg for treatment of his pain.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this patients case.  This medication at the doses prescribed to the patient is presently indicated for cancer pain in patients who are opioid tolerant and with a limited life expectancy.  This patient has non-malignant chronic daily headaches and facial 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 practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Baron and McDonald reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a pre-existing pain condition.  In this retrospective study, the majority of patients undergoing detoxification of high-dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia.  High-dose opiates may also cause adverse outcomes.  Ballantyne and Mao reported that prolonged use of high-dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects.  The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  In this patients case, OxyContin 40mg is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old male has requested coverage for past residential treatment center (RTC) services for treatment of his bipolar disorder and polysubstance abuse.  Findings:  The physician reviewer found that two progress notes from the patients therapist during the period in question are available. In the first note, the patient was informed by his provider that he would be attending partial hospitalization program (PHP) after discharge. He became upset when he realized he would have to go. The patient then talked about continuing to feel like he doesnt have a drug problem and that he has learned everything he needs to know. In the following progress note, the provider documents that the patient hates the treatment program and talked about feeling like the staff is corrupt and that he didnt learn anything from the program. He continued to talk about the injustices that have occurred in his mind with the staff and his peers. He was not able to identify his part in interactions and what he could learn from them. He continued to make excuses for why he has reacted negatively in different situations. Applying the American Psychiatric Association (APA) treatment guidelines, this patient had not developed an acceptance of his problem. He has not developed any appropriate skills to deal with his anger nor with his substance abuse. For these reasons, he meets the APA criteria for treatment at the RTC level of care during the time period at issue.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Repatha Sureclick. Findings:  The physician reviewer found that based on the records provided for review, the patient is a coronary risk including elevated LDL but no known coronary disease, a low coronary calcium score in 2014 and no documented ischemia on nuclear stress testing performed. In this circumstance of coronary risk without documented coronary ischemia or coronary disease and without a diagnosis of familial homozygous or heterozygous hyperlipidemia treatment with the PCSK9 inhibitor Repatha is not medically necessary and not considered standard accepted practice in the medical community. The diagnoses of familial homozygous or heterozygous hyperlipidemia require not only elevated LDL-cholesterol levels that significantly exceed 180, but also a combination of physical exam findings, a strong family history of coronary disease (younger than 50 years in second-degree relative or aged younger than 55-60 years in first-degree relatives) and documented genetic defects related to cholesterol metabolism according to published criteria. Repatha is a PCSK9 inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL-cholesterol.  This patient does not fit any of those criteria.  PCSK9 inhibitors have not been studied in other patient populations such as this patient. Also, current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting. Finally, there is no documentation that the patient has tried or was intolerant of Zetia, another medication class to reduce cholesterol and improve outcome. Final Result: The reviewers 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: Physician reviewer 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.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old male enrollee requested authorization and coverage of the medication Accutane for the threatment of acne.  The health plan denied the enrollees request indicating that the requested medication 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for Esketamine (Spravato) nasal spray for the treatment of major depressive disorder, anxiety disorder, and attention deficit hyperactivity disorder. Findings:  The physician reviewer found that treatment resistant depression is defined as a lack of significant improvement after two adequate trials of two different antidepressants from two different pharmacologic classes. There is insufficient evidence in the record this was done.  Many of the symptoms the enrollee reports are related to his anxiety/panic attacks; Esketamine is not FDA approved for the treatment of anxiety.  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 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: Overturned

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Rituxan (rituximab). Findings:  The physician reviewer found that Rituximab is an effective and accepted therapy for membranous nephropathy.  In the trial by Ruggenenti and colleagues, 100 patients with idiopathic membranous nephropathy with persistent nephrotic syndrome were treated with rituximab.  The authors noted that 65 patients achieved remission with therapy, and a large number who did not reach remission status had clinical improvement. The long-term effects of steroids are well-known. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: the physician reviewer is board certified in internal medicine with sub-specialty certification in nephrology 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.