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

A 45-year-old female enrollee has requested Provigil 200mg for the treatment of her bipolar disorder, sleep disorder due to night shift work, mood swings, anorexia, and past alcohol addiction. Findings:  The physician reviewer found that this patient has responded to Provigil prescribed by her treating physician which is FDA approved for shift work sleep disorder.  The patient did not respond to a trial on a psychostimulant and there are additional concerns regarding prescribing psychostimulants in patients with a history of substance dependence. Therefore, the use of Provigil is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 23-year-old male enrollee has requested reimbursement and prospective authorization and coverage for continued skilled nursing level of care including physical, occupational, and speech therapy, from a specific date and forward.  Findings:  The physician reviewer found that based on review of the available records, the patient is at a custodial level of care and does not require SNF level of care services. The records indicate that the patient has shown some very modest but largely inconsistent signs of progress, and is essentially in a minimally conscious state. He has not been tracking consistently or consistently following commands. He has been dependent for all care and mobility. Some ongoing recovery and functional progress may occur over the next 12-18 months, but the extent of rate of recovery is likely to be very slow given the severity of his injuries and the minimal progress that has been demonstrated since the initial accident. As such, further rehabilitative efforts can be provided at a lower level of care as no marginally significant improvement in health or functional outcomes is expected with ongoing SNF level care.  In the peer reviewed publications, Lombardi and colleagues literature review reported that, there is no reliable evidence to support, or rule out, the effectiveness of multisensory programmes in patients in coma or vegetative state. Similarly, a review by Meyer and colleagues on evidence-based interventions used to promote patient arousal from coma concluded that although each of the interventions showed promise and warrant further study, More methodologically rigorous study is needed before any definitive conclusions can be drawn. In addition, Georgiopoulos and colleagues noted that no therapeutic treatments were proven to be efficacious in significantly improving the recovery course or functional outcomes in the setting of vegetative state or minimally conscious state. Therefore, the requested multidisciplinary rehabilitative interventions including occupational, physical, and speech therapy is not medically necessary in lieu of care provided at a less intensive level such as custodial care with intermittent therapy services.  Consistent with these findings, the requested continued SNF care from the date in question and forward has not been shown to be medically necessary in the treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A forty-three year-old female with severe urticaria is requesting authorization of Xolair.Reviewers Findings:  The reviewing physician found that the FDA approved indication for Xolair is moderate to severe persistent asthma in patients who have: a positive skin test or in vitro reactivity to a perennial aeroallergen, symptoms inadequately controlled with inhaled corticosteroids, and pre-treatment total IgE levels of 30 or greater. The submitted records document the patient does meet the criteria. The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male has requested one hour per week of occupational therapy and one hour per week of speech therapy for treatment of his global developmental delays.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of one hour per week of occupational therapy and one hour per week of speech therapy in this patients case.  This patient has significant deficits in both receptive and expressive language skills.  At the time of the evaluation, he was not yet using any true words or following directions.  Speech and language therapy is particularly important for children with developmental delay to facilitate development of functional communication skills to express needs.  Children with global developmental delay are also at particular risk for feeding disorders because of oral motor weakness and decreased tone, as well as difficulties processing sensory information.  It is important to aggressively and thoroughly address these deficits to prevent further impact on growth and development.  This patient has delays in fine motor skills, self-help skills, and feeding skills.  Successful feeding interventions incorporate the services of occupational therapy, speech therapy, and nutrition in treating patients.  In addition, with its focus on developing teaching self-help skills including feeding skills, and developing fine and gross motor skills, occupational therapy is well-suited to affect positive change in this patients case.    All told, the requested one hour per week of occupational therapy and one hour per week of speech therapy are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested reimbursement for surgical laparoscopic implantation of a gastric electrical stimulator. Medical literature states that in refractory cases, especially when there is weight loss, invasive therapeutics such as insertion of feeding tubes, intrapyloric injection of botulinum toxin, implantable gastric electrical stimulation, or surgical (partial) gastrectomy are occasionally considered, but there is little evidence of efficacy, and these are not devoid of potentially major complications. The American College of Gastroenterology further noted that, gastric electrical stimulationdoes not adequately address clinical need. This patient has a history of nausea and heartburn possibly secondary to gastroparesis and GERD. The current peer-reviewed medical literature has not established the long-term safety and efficacy of a gastric electrical stimulator for use in this clinical setting. Therefore, the surgical laparoscopic implantation of a gastric electrical stimulator was not likely to be more beneficial for 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: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in gastroenterology 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: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee has requested Botox injections for the treatment of her chronic daily headache. Findings:  Two physician reviewers found that although chronic daily headache is reported, the frequency and severity of the patients headaches are not documented. The documentation suggests frequent use of narcotic analgesics, so medication overuse headache is likely. If the patient has medication overuse headache, it will substantially reduce the efficacy of Botox. She is not using typical acute migraine agents such as triptans. She has not tried a variety of standard migraine therapies, such as beta blockers and valproic acid. She carries a diagnosis of chronic headache, and it is unclear from the records that the International Classification of Headache Disorders diagnosis fits this patient. Given the likelihood of medication overuse, the absence of a clear headache diagnosis and inadequate trials of standard therapy, Botox is not indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400 mg  100 mg for eight weeks. Findings:  The physician reviewer found that According to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 1 patients should be treated with Epclusa for 12 weeks, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage based on a high cure rate. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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 internal medicine with sub-specialty certification in gastroenterology 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 47-year-old female enrollee has requested an electric scooter for the treatment of her medical condition. Findings:  The physician reviewer found that physiatry evaluation documents that the patients present assistive device is sufficient for her household mobility needs.  There is no evidence of impairment of mobility-related activities of daily living.  Therefore, although this patient has a mobility deficit, it is well addressed by the rolling walker with seat.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old male enrollee has requested for a CT coronary calcium study for evaluation of his coronary condition.   Findings:  Three physician reviewers found that CCT is not an accepted screening or confirmatory test for the diagnosis of coronary artery disease in this patient subset, and it is not a medically acceptable replacement for other conventional screening tests within the standard of care, such as treadmill stress testing. CCT is also not a medically acceptable substitute for coronary angiography, as CCT would not be able to accurately confirm or exclude important coronary obstruction. The use of CCT in the diagnosis and prognosis of coronary disease in this subset of patients remains an investigational application of this technology.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old female enrollee has requested an MRI of bilateral breasts for evaluation of her breast mass. Findings:  The physician reviewer found that this patient has a positive family history of breast cancer and has an abnormal mammographic and sonographic combination of findings which have been described as possibly growing.  An MRI should not be performed to preclude biopsy of a mass present on conventional imaging.  In this context, sensitivity is 85.4%, and negative predictive value is 67.4%, according to Bluemke and colleagues. The standard of care in this scenario includes ultrasound-directed core biopsy. This procedure yields superior diagnostic results compared to breast MRI and is likely to be of greater clinical utility in this setting.  In this patients case, the requested MRI of bilateral breasts is not likely to be superior over other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 48-year-old male who is status post multiple back surgeries. The submitted records indicate the patient is currently being medically managed with MS Contin. He has requested authorization and coverage for a spinal cord stimulator. The Health Plan has denied the patients request at this time, but has recommended a referral to a pain specialist for a second opinion.The Health Plans denial should be upheld. Upon review of the submitted documentation, it is not clear that the patients current pain management program would be significantly enhanced by implantation of a spinal cord stimulator. A second opinion evaluation by a board certified pain specialist is indicated prior to consideration of a spinal cord stimulator. The alternative services recommended by the Health Plan are medically reasonable and appropriate. As such, I have determined that the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

This case involves a 41-year-old female enrollee who requested authorization and coverage of compression stockings for the treatment of varicose veins.  The health plan denied the request, indicating that the requested stockings are not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested compression stockings are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 29-year-old female who has had the diagnosis of a bipolar disorder for the last six years. She has had multiple psychopharmacological interventions and a course of 11 ECT treatments in 2005. The last note concerning her current condition was dated February 2006 and was from an in-plan psychotherapist. The note states that the patient remains in a severe vegetative state with recurrent major depression without suicidal ideation.  The patient stated to her therapist that she did not see the point in continuing life.  The therapist stated that the patient did not wish to continue ECT due to severe pain and memory loss.  A return visit was scheduled for three months. The patient also sees a private therapist in the community and a psychiatrist in the community.  A note from the patients psychiatrist states that he has been managing the patients medication for five years.  He continues to see the patient one time a month.  He states that the patient remains severely depressed, meets the DSM IV criteria for a major depression and is now a candidate for VNS therapy.  The Health Plan has denied coverage for VNS therapy on the basis that its use for refractive depression is not medically appropriate given the insufficient quantity and quality of information supporting its efficacy.There is no doubt that the patient has had only transient response to multiple modalities of treatment that include: psychotherapy, pharmacological interventions, and ECT for the treatment of an atypical bipolar disorder. She is currently experiencing vegetative symptoms with no treatment recommendations from the Health Plan except for a follow-up appointment in three months. She is also receiving treatment from a non-plan therapist and psychiatrist. It is not clear how often she is seeing her psychotherapist or the type of psychotherapy she is receiving.  Her psychiatrist is treating her for 30 minutes each month.Although the patient has attempted multiple standard therapies with little or no benefit, the medical necessity of VNS therapy cannot be determined without the following additional information: the patients most recent progress notes from the Health Plan provider; a summary of the patients treatment and progress from the non-plan psychotherapist; a treatment summary from Cedars-Sinai concerning the impact of ECT treatments; and the alternative treatment options offered by the Health Plan. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. If the above-mentioned additional information is reviewed and demonstrates that the patient has exhausted all available standard therapy without success, then there is a possibility a trial of VNS therapy may be indicated and the patients request should be reconsidered.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 43-year-old female who is status post lumbar fusion and laminectomy in March 2005. She has an on-going complaint of left leg and lower back pain.  The patient was evaluated by an interventional pain specialist and sacroiliac (SI) joint arthrogram and piriformis, trochanter and sacroiliac joint injections were recommended for evaluation and treatment of her pain.  The Health Plan denied authorization based upon a determination that the procedures are not medically necessary.This patient is most likely experiencing post-surgical fusion/laminectomy back pain. The information provided in the record does not adequately demonstrate the need for SI joint, piriformis and trochanter injection therapy. Additionally, the current medical literature does not support the efficacy of these procedures. The article by Van Tulder is one example, and this study does not recommend injection therapy for the treatment of lower back pain. There is no class I data available to validate a supposition that injection therapy will improve long-term outcomes in the treatment of lower back pain.   Therefore, I have determined the requested procedures are not medically necessary for evaluation and treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injection series in both knees. Findings: Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from prior injections with lasting relief. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Orthovisc injection series in both knees 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 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oxycodone/acetaminophen. In this case, the patient reports lumbar back pain secondary to lumbar spondylosis and vertebral body hemangiomas. The records document that the patient has a signed opioid contract on file. However, as noted in the current medical literature, chronic opioid therapy is not considered the first-line treatment for chronic lumbar back pain. In this case, there is no documentation of trials of first-line medications or non-medication attempts at conservative care. Without documentation of attempts at conservative care or evidence of adequate trials of first-line medications to control the patients pain, the requested oxycodone/acetaminophen 7.5 mg/325 mg every four hours, for a quantity of #180 every 30 days, or oxycodone/acetaminophen 5 mg/325 mg, two tablets every four hours, for a quantity of #360 every 30 days, is not medically necessary. 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 anesthesiology with subspecialty certification in pain management 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 male enrollee has requested a portable oxygen concentrator for the treatment of the enrollees chronic obstructive pulmonary disease (COPD).  Findings:  The physician reviewer found that the submitted clinical information demonstrates that the patient has severe COPD and cor pulmonale, which requires that he be on supplemental oxygen at a rate of 2 LPM, 24 hours per day. Currently, the patient has a home oxygen concentrator as well as a conserving device. There is no evidence that this equipment is not functioning properly. The patient is requesting that he receive a portable oxygen concentrator, preferably one that is FAA approved, so that he may travel for both work and pleasure.  The requested equipment is being sought for convenience and ease of travel and therefore is not medically necessary for treatment of the patients medical condition.