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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for a Myocycle functional neuromuscular electrical stimulation. The patient is a 34-year-old male who sustained a spinal cord injury from a gunshot wound at T1-T6 with complete cord lesion and resultant lower limb paralysis. The treating physician requested a Myocycle home functional neuromuscular electrical stimulation device. The physician indicated the patient was an excellent candidate for the equipment due to the nature of his condition and his noted willingness to comply with the prescribed functional neuromuscular electrical stimulation cycling program. The physician stated that the cycle therapy system had multiple medical, physical, and functional benefits that made it medically necessary for the patient. The patient is a young individual who could make functional gains after his spinal cord injury. The Myocycle can also slow or prevent contractures, spasm, and skin breakdown. The scientific evidence in peer-reviewed literature supports improvement in health outcome including bone density, muscle mass, and mobility. The Myocycle functional neuromuscular electrical stimulation has received approval from the Food and Drug Administration and it has been deemed effective for this diagnosis. The patient is a good candidate for the Myocycle.Final Result: The reviewers determined that the Myocycle functional neuromuscular electrical stimulation provided on 4/22/20 was likely to be more beneficial than any available standard therapy for the treatment of the enrollees medical condition.Credentials/Qualifications: One physician reviewer is board certified in neurology and two physician reviewers are board certified in physical medicine and rehabilitation. All physician reviewers are actively practicing. All 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 25-year-old male with a long-standing history of depression and stimulant abuse, abstinent from 2000 to 2003, but suffering continued symptoms of notable loss of energy and motivation, oversleeping, overeating, poor self-esteem and a very bleak outlook. The patient had received Lexapro 30 mg, Effexor XR 300 mg and Neurontin 800 mg for some months, but with no improvement. Because of the extent of his depression and relapse of stimulant use the patient was admitted to residential treatment in April 2005 where he remained until July 2005. Past trials of Prozac, Zoloft, Celexa, and Wellbutrin had only led to increased anxiety and difficulty with sleep continuity. Past trials had also included Depakote and Lamcital, but both ended because of a perceived lack of benefit. At the time of his admission to residential treatment, the patients depression was rated approximately 8/10 and admission diagnoses included Major Depression, Recurrent, Severe and Polysubstance Dependence, with rule-out of Bipolar Disorder.Chart notes evidence the patient as quite depressed with continued tendency to oversleep and overeat with very poor motivation or improvement in outlook. Lithium and Abilify were added to his regimen and he eventually improved. On many occasions he was noted as also considering returning to stimulant use once out of the program.Given the extent of the patients depression and stimulant abuse to counter it, with a fairly wide variety of antidepressant trials tried on an outpatient basis but to no avail, residential treatment did appear indicated. The chart notes document the patients depression as quite prevailing with a concurrent concern about his imminent return to stimulant abuse. Given the strong comorbidity between the patients depression and substance abuse, residential treatment was the optimal treatment milieu in which to find an improved medication course as well as interrupt his return to stimulants.Based upon the information set forth above, I have determined the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 38-year-old female enrollee has requested inpatient psychiatric hospital services for treatment of her behavioral health condition. Findings:  The physician reviewer found that the inpatient psychiatric hospital services provided from the specified date forward were and are medically necessary for treatment of the patients medical condition. The medical records submitted for review indicate that the patient is not capable of taking care of herself. This patient is not at baseline behavior, as at baseline she was living independently. At baseline the patient was receiving injectable antipsychotic medication. The medical records indicate that as of the specified date, the patient began receiving the olanzapine 10mg intramuscular (IM) injections each time she refused her oral dose. According to the records the patient consistently refused her oral dose, so she was consistently receiving IM medications. Initially, she was very resistant, however after awhile she still refused, but when confronted she allowed the injection. Thus, the injections cannot be administered in a less restrictive environment, due to her non-compliance. The record notes that the patient continued to refuse oral medications and received injections until the specified date. Finally, the patients treatment plans notes that the patient did show some improvement with her psychotic symptoms, but she still has not progressed to performing well enough to be discharged to a lower level of care. Therefore the medical necessity for continued inpatient psychiatric hospital services provided from the specified date forward has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for neurotherapy. Papatola and Lustig defined the medical necessity of healthcare as services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. This patients records document the patient is already receiving services to meet his essential health needs in the form of case management, social skills groups, and CBT therapy. In the peer-reviewed medical literature, there is limited evidence of the effectiveness of neurotherapy on treating autism symptoms. Moreover, neurotherapy does not meet the current medical guidelines for effective treatment of patients with autism. Based on the current information, the requested neurotherapy is not medically necessary for treatment of this patients medical condition. 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 a licensed psychologist and a board certified behavioral analyst 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 is requesting authorization and coverage for Synvisc-One injections to the right knee. The enrollee has osteoarthritis of the right knee. He reportedly has tried cortisone injections without relief. An examination of the right knee showed restricted and painful range of motion. The provider noted medial and femoral condyle tenderness, and a positive patellar grind test. A Synvisc-One injection was administered to his right knee. At a follow up visit, the enrollee reported significant pain relief from the previous Synvisc-One injection. He also noted he was able to decrease his use of anti-inflammatory medications. A repeat Synvisc-One injection was recommended. A professional society reports the use of intra-articular hyaluronic acid injections is indicated for the treatment of osteoarthritis in the knee in adults who do not respond to other treatment options. Records show the enrollee has knee arthritis and has trialed previous nonsurgical treatment options, as well as surgical treatment, without resolution of symptoms. The use of viscosupplementation (Synvisc-One) injection to aid in the treatment of osteoarthritis is standard practice.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Ultomiris (ravulizumab-cwvz), or in the alternative, Solaris (eculizumab).Findings:  The physician reviewer found that current development shows that complement inhibition in renal disease is actively pursued in several clinical studies. Initial proof of concept comes from the inhibitor Soliris. The records provided for review document that this patient has a chronic condition that requires treatment. Without therapy, the patients glomerulonephritis is likely to recur. Restarting therapy prior to recurrence will prevent further loss of long-term renal function. The change to the Ultomiris, which is every eight weeks, instead of every two week treatment with Soliris, will also have a significant impact on the patients quality of life. Given these findings, the requested Ultomiris (ravulizumab-cwvz) is medically necessary for treatment of this patient. 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 reviewer is board certified in internal medicine with subspecialty 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.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old female enrollee has requested continued outpatient psychotherapy, at a frequency of five times per week or any other frequency greater than two sessions per week, and for outpatient psychotherapy at a frequency of five times per week, or any other frequency greater than one session per week, for treatment of her dysthymic disorder.  Findings:  The physician reviewer found that effective psychotherapy is a trusted intervention in the treatment armamentarium for those diagnosed with affective disorders, such as dysthymia. Current practice is focused on aggressive treatment, particularly in the acute phase of the illness, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery. The optimal frequency of psychotherapy has not been rigorously studied in controlled trials. The psychiatrist should consider multiple factors when determining the frequency for individual patients, including the specific type and goals of the psychotherapy, the frequency necessary to create and maintain a therapeutic relationship, the frequency of visits required to ensure treatment adherence, and the frequency necessary to monitor and address suicide risk and other safety concerns. Time-limited brief psychotherapies may mobilize many depressed patients to more rapid improvement. Regardless of the type of depression-focused psychotherapy that is selected, the clinician should carefully and systematically monitor the patients response to treatment, which can be facilitated by the use of clinician and patient rated scales at regular intervals. (Gelenberg, et al.)Considering that the mean duration of a properly completed psychoanalytic case is approximately 1,000 sessions, (American Psychoanalytic Association) 11 years of sessions at a rate of 5 per week would well exceed the benchmark for psychoanalysis, if that is indeed the therapeutic approach being utilized. There is no other evidence-based psychotherapy that recommends treatment at such a frequency. In the maintenance phase of this patients treatment, psychotherapy at a frequency of two hours per week would have been medically appropriate. Thus, as of the said date, outpatient psychotherapy at a frequency of two sessions per week was medically necessary for this patient. With regard to future treatment, standard of care in this setting would include revisiting the treatment plan with consideration given to time-limited therapies (Gelenberg, et al.), such as behavioral therapy, cognitive behavioral therapy, cognitive bibliotherapy, problem-solving therapy, brief psychodynamic therapy and life review therapy (Fiske, et al.), and selective serotonin reuptake inhibitors (Cuijpers, et al.). Given that treatment thus far has failed to achieve sustainment in the maintenance phase, and while the treatment plan is revised to facilitate the desired end state of affective harmony and individual autonomy, continued outpatient visits twice a week are reasonable and medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco and appetite suppressants for treatment of the enrollees chronic low back pain and obesity. Findings:  The physician reviewer found that the medical records show the patient has chronic nonmalignant low back pain. In terms of weight loss, there is no evidence that the patient has failed a weight loss program including a low calorie diet and increased physical activity. A trial of pool therapy with a self-directed aquatic program would be a potentially ideal treatment for both his low back pain and as a mean of weight loss. In addition, non-opioid alternative therapies for pain treatment should be tried before resorting to chronic opioid therapy including pharmacologic therapy with non-opioid pain medications such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) as well as physical activity including graded exercise matched to the condition being treated. There are complementary treatments such as acupuncture, massage, and yoga that can also be considered for this patients medical conditions. 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 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested 16 hours total of skilled nursing services per day for treatment of her medical condition.  Findings:  The physician reviewer found that the patient has end-stage amyotrophic lateral sclerosis.  The patient receives eight hours of skilled nursing services and the request is for an additional eight hours of service.  The documentation submitted does not support that the patient has had any new medical complications that would require an additional eight hours per day of skilled nursing services.  The Health Plan is currently providing eight hours of care daily by a skilled nurse which is adequate for oversite of plan of care and wound care.  The patient requires custodial care 24 hours a day, around the clock.  A skilled nurse is able to teach a layperson to care for a feeding tube and to suction via the tracheostomy.  Currently, the patient is not having an active infection or complication that would require an additional eight hours of skilled nursing service a day.  All told, the requested 16 hours total of skilled nursing services per day is not medically indicated for the 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 internal 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: Experimental/Investigational
Decision: Upheld

The representatives of a 59-year-old female enrollee requested authorization and coverage of a PET scan. The Health Plan denied the request indicating that the requested PET scan is considered experimental for treatment of the enrollees possible dementia.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested PET scan is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested PET scan is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Edarbyclor 40-25 mg for treatment of the enrollees hypertension. Findings:  The physician reviewer found that In the medical literature the Eighth Joint National Committee (JNC 8) support the use of monotherapy before use of combination or second agents. In addition, the use of step therapy with anti-hypertensive medications and requiring trial of formulary medications before approving other similar medications is considered within the standard of care. Multiple choices are offered by the Health Plan including Avapro, Avalde, Cozaar, Hyzaar, Diovan, and Diovan HCT. These options are very similar medications in the angiotensin receptor blocker (ARB) class. All told, the requested Edarbyclor 40/25 mg is not supported as medically necessary for treatment of this patients hypertension. Final Result: The reviewer determined that the requested medication is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The 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

The parents of a 10-year-old male enrollee have requested a partial hospitalization/therapeutic seven week summer program for the treatment of the enrollees bipolar disorder, not otherwise specified, generalized anxiety disorder and attention deficit/hyperactivity disorder. Findings:  The physician reviewer found that this patients level of functioning is not such to support treatment in the requested partial hospitalization/therapeutic program. While the patient does require continued therapy, the submitted documentation does not demonstrate that he is acutely impaired to the level that necessitates treatment in a partial hospital program. There is no mention in the records provided of family therapy as a treatment modality for this patient, which would be appropriate in this setting. The data available does not suggest that this patient would regress if not treated in the requested partial hospitalization program. His clinical need for the structure, monitoring and related services of a partial hospitalization program is not demonstrated. Continued care at a lesser level of intervention, such as an intensive outpatient program, is medically appropriate in this setting.
Appeal type: Medical Necessity
Decision: Upheld

A 22-year-old female enrollee requested substance abuse residential treatment center services for medical treatment of her substance abuse. Findings:  The physician reviewer found that the patient did not have psychiatric or significant medical comorbidity which would interfere with her maintaining abstinence and recovery, nor did she have evidence of major functional impairment in any domains. The patient was not at risk of developing withdrawals. She did not have significant medical or psychiatric comorbidity. She did not show suicidal or homicidal ideation, plan, or intent.  She was motivated and engaged in her treatment plan. She recognized her relapse triggers and her family was supportive of her recovery efforts. In sum, the patient did not meet American Society of Addiction Medicine criteria for residential level of care. Based on the medical literature cited above and the documentation submitted for review, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested Reclast injections for the treatment of her medical condition. Findings:  The physician reviewer found that the medication has been granted FDA approval for the treatment of postmenopausal women with osteoporosis, and men with osteoporosis, as defined by a T score of less than -2.5, as well as for the prevention of osteoporosis while on glucocorticoid therapy and Paget's disease. It has not been approved for the prevention of osteoporosis. This patient did not meet the criteria for Reclast treatment under the FDA label.  Nor was the off-label use of the drug medically necessary as there is no evidence that other causes of bone loss were ruled out or that the patient had adequate vitamin D levels. A consultation with a specialist in osteoporosis for further evaluation would have been the next appropriate step for this patient rather than proceeding with Reclast therapy.