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

The patient is a 53-year old male admitted for acute medical care in November 2005 continuing through March 2006.  He underwent LVAD placement in December 2005 and closure of tongue wounds in March 2006.  He had a subsequent rupture of the tongue wound with massive bleeding and returned to surgery.  The patient participated in physical and occupational therapy during his acute medical hospitalization.  According to the physical therapy notes he received physical therapy twice per day in March 2006 with LVAD precautions. He required moderate two person assistance to stand and transfer and minimal assistance for ambulation from 120 to 600 feet. As of March 2006 he was independent with upper body activities of daily living (ADLs) and needed maximal assistance with lower body ADLs.  The patient was transferred to the acute rehabilitation program in March 2006 and was not taking anything by mouth at that time.  He was fed via nasogastric tube secondary to his tongue wound. He worked closely with speech therapy and began oral feeding in March 2006.  The patient required careful monitoring to advance his diet.  Per the physician notes, at the time of admission the patient had an LVAD, a PICC line, several open wounds, and required careful medical monitoring by his physician.  Physical and occupational therapy findings during acute rehabilitation were consistent with his previous therapy. He continued to make slow progress through March 2006 when he was discharged home.The patients request for reimbursement for the acute rehabilitation services was denied by the Health Plan based upon a determination that the services were not medically necessary.Based on the records provided, the patients primary rehabilitation issue was general deconditioning.  In most cases this problem in and of itself, would not have required acute rehabilitation and the patients progress with therapy was somewhat slow. However, the patients medical problems were significant and he required daily medical evaluation and acute nursing care in addition to his on-going rehabilitation needs. The necessary level of medical care could not have been provided in a subacute or skilled rehabilitation program. Therefore, I have determined the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for a computed tomography (CT) scan of the brain. This patient complains of headaches that have persisted for a number of days. She complains of fever, chills, headache, nasal congestion, and cough. The patient reports that her cough is producing green sputum. The patients neurological examination has been unremarkable. The records provided for review do not suggest that the patients complaint of headaches is due to a central nervous system process. The patients history and findings are suggestive of an upper respiratory infection. The CT brain imaging is not likely to provide any insight with relation to occipital neuralgia. All told, the requested CT scan of the brain is not medically necessary for evaluation of this patient.Final Result: The reviewer determined that the requested services are 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 neurology 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: An enrollee has requested authorization and coverage for Genotropin. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee who has a history of growth failure.Findings:  According to  the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations (SD) below the mean for age or more than 2 SD below the mid-parental height percentile; (2) growth velocity < 25th percentile for bone age; (3) bone age more than 2 SD below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. According to the submitted record, this patient meets most of the above criteria. Therefore, continuation of GH therapy for treatment of the patients idiopathic short stature has been demonstrated as medically necessary. Final Result: The reviewer has determined 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 pediatrics with a sub-specialty certification in pediatric endocrinology 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

An enrollee has requested authorization and coverage for Magnetic Resonance Imaging (MRI) of the cervical spine.The submitted documentation supports that the requested services are medically necessary. Evidence based medical guideline criteria state that MRI is usually appropriate for patients with new or increasing cervical radiculopathy and for patients with chronic neck pain when radiographs show degenerative changes, and particularly after failure of conservative management or when surgery is contemplated, for operative planning. In this case, the patient presents with a history of neck and left shoulder pain. He reports increasing neck pain, headaches, and left upper extremity pain, weakness, numbness and tingling. Functional limitations are now reported affecting his work ability. There is prior imaging evidence of significant spinal degenerative changes with nerve root compromise and potential cord compromise. The patient is reportedly ready to pursue surgical intervention, which was previously recommended but delayed. He has failed long-term conservative treatment, including physical therapy, activity modification, injection therapy, and medications. He has been referred for neurosurgical consultation and a pre-consult updated cervical spine MRI is required by the neurosurgeon. Under these circumstances, the requested Magnetic Resonance Imaging (MRI) of the cervical spine is medically necessary for the patients medical condition.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: An enrollee has requested reimbursement, authorization, and coverage for acute inpatient psychiatric services. Most evidence-based treatment guidelines concur that the deciding factor on whether inpatient psychiatric care is necessary is whether patients appear to be a harm to themselves or others. Milliman guidelines agree on this point and additionally cite factors such as overt psychotic ideation, complex biomedical issues, grave disability impairing daily living function, and/or high levels of impulsivity, aggression or mania. In this case, the patient was not evincing suicidal or homicidal ideation. He was not expressing overt psychosis. There was no issue of self-injurious behavior or complex medical issues.  Although he was still showing some elements of grave disability, he was not functionally impaired in all areas of daily living such that he required inpatient level of care. There was no evidence of gross impulsivity, aggression, or mania. The patient could have been treated at a lower level of care with less restriction, such as residential.Final Result: The reviewer determined that the requested services 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 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 Otrexup (methotrexate) 25 mg/0.4 mL subcutaneous auto-injector pen. The medical literature supports the efficacy of methotrexate for the treatment of patients with chronic recurrent multifocal osteomyelitis (CRMO). In a retrospective study, Borzutzky and colleagues reported that 20% of patients treated with methotrexate demonstrated clinical remission. Zhao and colleagues demonstrated support for oral methotrexate or subcutaneous methotrexate injections for patients with CRMO refractory to treatment with non-steroidal anti-inflammatory drugs (NSAIDs). In this case, the patients records document that she was unable to tolerate first-line therapy with the celecoxib, which is an NSAID. The provider noted that celecoxib was contributing to exacerbation of the patients ulcerative colitis symptoms with rectal bleeding. The patient was then treated with injectable methotrexate in the form of the Otrexup 25 mg/0.4 mL auto-injector pen. Based on current medical literature and guidelines, methotrexate is an appropriate choice for CRMO as an alternative to NSAID therapy. However, according to the consensus treatment plan, treatment with methotrexate in this patients clinical scenario can be in oral or injectable formulations (Zhao, et al.). Thus, the use of oral methotrexate is appropriate and consistent with current recommendations. All told, the requested Otrexup (methotrexate) 25 mg/0.4 mL subcutaneous auto-injector pen is 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a vitamin D screening assay (CPT code 82306), stress echocardiography (CPT code 93351), and carotid duplex ultrasound (CPT code 93880). The records provided for review document that this patient presented with symptoms of chest tightness and risk factors for coronary artery disease (CAD) including age, gender, and hypertension. Evaluation with a stress echocardiography was conducted as a diagnostic test for these symptoms and risk factors. The stress echocardiography revealed an upsloping ST segment depression, which is abnormal, and places him in an intermediate risk group for CAD. However, stress echocardiography is not supported by American College of Cardiology Foundation (ACCF) guidelines for use in this clinical setting. Based on the guidelines, the standard of care is evaluation with a plain treadmill test. The decision to use imaging modalities in lieu of a standard treadmill test is based on the appearance of the resting electrocardiography (EKG). The records do not report that a resting electrocardiography was performed to support an indication for the stress echocardiography. Given these findings, the stress echocardiography (CPT code 93351) was not medically necessary for evaluation of this patients symptoms and risk factors for CAD. With regard to vitamin D screening, researchers found that the current research does not support the use of vitamin D levels to help determine cardiovascular risk. The authors reported that meta-analyses of vitamin D supplementation trials have failed to show clear improvements in blood pressure, insulin sensitivity, or lipid parameters. Thus, the vitamin D screening assay (CPT code 82306) was not medically necessary for evaluation of this patient. Further, the ACCF states that a carotid duplex scan may be indicated if a bruit is audible or if there are symptoms of cerebral ischemia. This patients records do not report the presence of an audible bruit or symptoms of cerebral ischemia. Accordingly, the carotid duplex ultrasound (CPT code 93880) was not medically necessary. Final Result: The reviewer determined that the services at issue were 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 subspecialty 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

Nature of Statutory Criteria/Case Summary: A male enrollee has requested reimbursement for the Monovisc injection for treatment of the enrollees knee pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient is being treated for near end stage osteoarthritis of the knee. The quality of data to support the efficacy of viscosupplementation for the treatment of knee osteoarthritis is questionable. Multiple large specialty governing bodies do not recommend viscosupplementation given the lack of consensus high-quality evidence.  Specifically in this case, there has been a pattern of decreased duration of symptomatic relief of less than six months.  Thus, an additional series of viscosupplementation was not supported. All told, the Monovisc injection was not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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

The parent of an 18-year-old male enrollee has requested for adolescent substance abuse sub-acute residential rehabilitation services for treatment of the enrollees cannabis dependence, hallucinogen abuse, alcohol abuse, obsessive-compulsive disorder and substance-induced anxiety disorder. Findings:  The physician reviewer found that the patient was in no acute distress at the time of admission to the sub-acute center. There was no evidence of suicidal or homicidal thoughts and no signs of psychosis. His drug use could have been effectively and safely treated at a lesser level of care.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee has requested bilateral knee Synvisc One injections for treatment of her osteoarthritis.  Findings:  The physician reviewer found that in the medical literature, Waddell and colleagues indicated that the usefulness of viscosupplementation in the treatment of osteoarthritis of the knee has been generally accepted, although some questions have been raised. Bellamy and colleagues discussed some comparative studies evaluating different products with regard to their relative value but found inadequate evidence supporting the superiority among the different available hyaluronic acid formulations. In addition, Wang and colleagues concluded that additional well-designed, randomized, controlled trials are still needed to resolve the uncertainties regarding the effects of different products in varied clinical situations and patient populations. Since there is a lack of evidence supporting the increased efficacy of the requested Supartz One injections over standard alternatives, its use has not been demonstrated as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 53-year-old woman requesting Inspra for treatment of her secondary hyperaldosteronism (SHA) associated with nephropathy and hypertension. She has been tried on spironolactone to block aldosterone receptors, but has been intolerant. The patient has nodular hyperplasia of the adrenals and high levels of aldosterone and renin even off medications. The Health Plan has denied coverage for Inspra on the basis it is not medically necessary for treatment of the patients condition.This patient continues to have abnormally high levels of renin and aldosterone and evidence of nodular hyperplasia of both adrenals after discontinuation of spironolactone and diuretics. Other secondary causes for the patients nephrology, hypertension, and hypokalemia have been ruled out. Inspra has been approved for use in patients with hypertension or congestive heart failure. It is a standard treatment for patients who have SHA with hypertension and hypokalemia and who are intolerant to spironolactone. Therefore, I have determined the requested medication is medically necessary for treatment of the patients condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for 90-count of 40 mg of OxyContin each month and 90-count of 10 mg of OxyContin each month for treatment of the enrollees chronic neck pain. Findings:  The physician reviewer found that several requirements for opioid prescribing have not been documented, so the need to use them as the primary medication treatment strategy for pain has not been established in this clinical setting. The Centers for Disease Control and Prevention (CDC) state that when opioids are started, providers should prescribe the lowest effective dosage. The CDC states that when starting opioid therapy for chronic pain, clinicians should prescribe immediate release opioids instead of extended release/long-acting (ER/LA) opioids. Providers should use caution when prescribing opioids at any dosage and should carefully reassess evidence of the individual benefits and risks when considering increasing dosage to 50 or greater morphine milligram equivalents (MME) per day, and should avoid increasing dosage to 90 or greater MME per day. It is recommended to carefully justify a decision to titrate dosage to 90 or greater MME per day. In the documentation available for review, no objective treatment goals for pain and function are noted for this patient to continue on the requested medication. There is no medical evidence based rationale is given for this high of a MME/day by the provider or by the patient. It is unclear what the plan is for any unseen future pain insults the patient would experience while on the requested medication quantity. Dose escalation is not a long term plan but a short term plan for the treatment of tolerance. There is no documentation that other non-pharmacological alternatives of addressing this patients pain have been initiated. The record does not mention completion of behavior therapy despite much research to support its use. Finally, not all non-opioid medications classes have been optimized or tried. Final Result: The reviewers determined that the medication quantity was not and 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 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: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the hips.The submitted documentation fails to demonstrate the medical necessity of the requested service. Ward and colleagues noted, In adults with ankylosing spondylitis of unclear activity while receiving a biologic, we conditionally recommend obtaining a spinal or pelvis MRI to assess activity. (Ward, M., et al.). In this case, the patient has ankylosing spondylitis with a history of biologic therapy use. The patient reports of pain in the hips and buttock area. On 1/13/21, the records indicate that the patient had bilateral sacroiliac joint tenderness on palpation during physical examination, which is suggestive of sacroiliitis. No abnormality of hip examination was reported. According to current guidelines, obtaining an MRI of the hip joints to assess ankylosing spondylitis disease activity is not recommended. Thus, the requested MRI of the hip joints is not medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the requested service 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 certification in 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

A 62-year-old female enrollee has requested for Supartz injections for treatment of her right knee pain.    Findings:  The physician reviewer found that she appears to have tried and failed NSAIDs in the past, but has not tried other conservative measures, such as cortisone injections. As there are other treatments available that are likely to be efficacious for this patient, Supartz is not medically indicated at this time.