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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication, Vyvanse. The enrollee has a history of major depressive disorder, generalized anxiety disorder, panic disorder, post-traumatic stress disorder, and attention deficit hyperactivity disorder. The enrollee reported concerns of binge eating over the last two months with an eight-pound weight gain over the last month. She reported increased stress, and increased symptoms of anxiety, depression, and attention deficit hyperactivity disorder. The enrollee requested a medication that would help to curb her excessive hunger. Her provider prescribed Vyvanse to control attention deficit hyperactivity disorder and binge-eating symptoms. The record indicates the enrollee stopped taking Ritalin, as it was not controlling her symptoms. Subsequently, the provider ordered extended-release Concerta. The enrollee indicates Ritalin caused weight gain, Concerta resulted in severe headaches, and Wellbutrin elevated her heart rate and blood pressure. Therefore, Vyvanse has been prescribed. Vyvanse is a long-acting amphetamine indicated for attention deficit hyperactivity disorder. The record shows Ritalin was prescribed for difficulty with concentration. However, there is insufficient evidence in the record of other symptoms, or the use of rating scales to support this diagnosis and to evaluate the enrollees response to treatment. Difficulty with concentration is one of the symptoms demonstrated in patients with attention deficit hyperactivity disorder, but the diagnosis cannot be made based on this one symptom alone. Difficulty with concentration is seen in many other medical and psychiatric conditions. The enrollee was taking short-acting Ritalin twice per day, with the second dose in the evening, which was contributing to her insomnia. Ritalins average effect is three to four hours. It is generally not taken in the evening, as inadequate sleep is often one of the contributing factors to difficulty with concentration. The records indicate the patient was reporting weight gain on Ritalin. However, Ritalin causes a decrease in appetite. Vyvanse was recommended because of the patients binge eating. Although Vyvanse is approved for the diagnosis of binge eating disorder, the medical record contains insufficient evidence of symptoms to support the diagnosis of binge eating disorder.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: A retrospective request was received for a Synvisc One injection that had been administered to the left knee joint. The Health Plan has denied this request indicating that the service at issue was not medically necessary for treatment of the enrollees osteoarthritis.A review of the records revealed she was status post arthroscopy of the left knee for degenerative meniscal tears and chondromalacia. The documentation indicates persistent pain, mechanical symptoms, and lack of response to conservative treatment. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee chondromalacia/osteoarthritis. Recommendation of intra-articular hyaluronic acid for management of knee osteoarthritis as second-line treatment in patients who remain symptomatic despite use of non-steroidal anti-inflammatory drugs is based upon accumulating evidence that intraarticular hyaluronic acid provides a significant benefit in knee osteoarthritis.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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Privigen 500 mg IVIG therapy. The submitted documentation supports the medical necessity of the requested treatment. BK viremia is associated with poorer outcomes with renal allografts. The risks of allograft failure are great. IVIG therapy is considered standard of care for this particular condition and has been shown to be effective. Options for this patient are limited, and the consequences of failed therapy are severe. Under these circumstances, IVIG therapy is not only indicated, but would be considered standard of care. Accordingly, Privigen 500 mg IVIG therapy is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested treatment 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Aquatic Therapy.Exercise in an aquatic setting is one of several options for exercise that can potentially provide symptom relief for various pain conditions (Verhagen, A., et al.; Baena-Beato, P., et al.). It is thought that the warmth and buoyancy of water may help block nociception by acting on thermal and mechanoreceptors, thus influencing spinal segmental mechanisms (Kamioka, H., et al.). The evidence-based literature, nevertheless, has not demonstrated that aquatic exercise is an effective intervention for back pain overall (Kamioka, H., et al.; Morelhao, P., et al.). There are no proven or expected marginal benefits of formal aquatherapy programs over water-based exercises that are pursued independently or performed in informal group exercise settings. Various water-based exercise programs not requiring formal therapy have been reported to be effective and can be pursued empirically (Keane, L.). Formal aquatic therapy (i.e., as opposed to generalized water-based exercise) is medically necessary only for individuals in specific circumstances, i.e., for patients who require therapy in a partially body weight unloaded environment (e.g., persons with fractured limbs and significant weight-bearing restrictions, or profound neurological weakness such as tetraplegia). These candidates are unable to perform the applicable exercises safely and effectively without formal therapist guidance, instruction and supervision, and cannot be safely and effectively overseen, supervised and instructed by persons without formal therapy training.In this case, the records do not establish that the patient has condition(s), impairment(s) or restriction(s) that would preclude an appropriate informal water-based or low-impact land-based exercise program. There are no documented, objective indications that the patient could not exercise in a pool on his own (e.g., basic pool walking, stretching, strengthening and/or swimming), in a group exercise setting, or with an exercise coach (without a physical therapist's license) if he elected to do so. The submitted records do not establish that a formal aquatic therapy program is medically necessary for this patient. Accordingly, the requested Aquatic Therapy is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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 40-year-old male enrollee requested authorization and coverage of a craniotomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees arachnoid cyst.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) treatments provided for treatment of the enrollees major depressive disorder. Findings: Two out of three physician reviewers found that according to the Clinical TMS Society While peer-reviewed studies demonstrate that the majority of patients who receive acute benefit from TMS therapy do so within 4-6 weeks, it is reasonable to continue treatment beyond 6 weeks in specific circumstances. In this case, although the patient had improved, a plateau had not been obtained. The note stated that the patient was experiencing improvement, was working every day, and that her energy was returning. The provider noted the patient was definitely better. Given the significant improvement in the patients symptoms noted in the record, the TMS treatments were clinically indicated within weeks. As such, the TMS treatments provided were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy, but not thereafter. Final Result: The reviewers determined that a portion of the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 are 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: Overturned

A 44-year-old female enrollee has requested for a power wheelchair for treatment of her medical condition. Findings:  The physician reviewer found that the use of a power wheelchair in this setting is consistent with Medicare guidelines. This patient has a personal mobility deficit that significantly impairs her participation in mobility-related activities of daily living (such as toileting, feeding, dressing, grooming, and bathing) in customary locations within her home. Her mobility deficits are not presently ameliorable by a walker, cane, prostheses or manual wheelchair. As such, the patient meets medically necessary criteria for a power wheelchair until such time that she is appropriate for the use of prostheses.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for speech therapy services. Findings:  The physician reviewer found that The submitted documentation supports that the requested services are medically necessary. Maiano and colleagues estimate that 44 percent of children with autism are bullied at school. This is frequently due to their difficulty interacting appropriately with others. Helland and colleague recommend that the substantial influence of pragmatic language abilities on social function and in resolving interpersonal conflicts with peers needs to be considered in children with autism and that further development of therapy plans and interventions targeting pragmatics is strongly needed. Loukusa and colleagues discuss methods of exploring deficits in the pragmatic language in children with autism using the Pragma test, the Social Interaction Deviance Composite (SIDC) of Children's Communication Checklist-2 (CCC-2), and the Theory of Mind subtest of the Developmental Neuropsychological Assessment, Second edition (NEPSY-II). The results of their research showed that children with autism differed from typically developing children in questions demanding context utilization. In this case, the patient has been diagnosed with autism spectrum disorder, and he is noted to be the target of bullying at school because of his impairments in the appropriate social use of pragmatic language. Under these circumstances, the requested speech therapy services are medically necessary to treat 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 pediatrics and neurology, with special qualification in child 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: Upheld

A 35-year-old female enrollee has requested intravenous Rocephin (ceftriaxone) treatment for her diagnosis with Lyme disease.  Findings:  The physician reviewer found that this patients symptoms include headache, facial twitching and cognitive complaints that have been present for a decade.  In 2010, she had an EEG that showed findings consistent with an epileptiform focus.  There is no clinical history consistent with Lyme disease.  No notes in the record document a tick bite, nor is there evidence of the rash seen in a significant proportion of patients with early Lyme disease.  The patients symptoms have been nonspecific.  Late Lyme disease may be associated with a variety of neurological symptoms, although there are usually manifested as encephalopathy or cranial nerve palsies.  Evidence of epileptiform activity is unusual as a finding in central nervous system Lyme disease.  There have been no positive Western Blot IgM antibodies by Centers for Disease Control criteria.  The IgG Western Blot for Borrelia would be expected to be positive in longstanding Lyme disease, and these tests have been negative.  There is a lack of clinical or laboratory evidence demonstrating that the patients symptoms are caused by infection with Borrelia burgdorferi.  All told, intravenous Rocephin (ceftriaxone) was not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 31-year-old female enrollee has requested intrastromal corneal ring segment for the treatment of her keratoconus. Findings:  Two physician reviewers found that patients with keratoconus have very poor vision with spectacle correction due to the large degree of irregular astigmatism induced by the warped cornea. This patient had become contact lens intolerant. Therefore, the only options remaining to provide functional vision were implantation of intrastromal rings and penetrating keratoplasty. Intrastromal corneal ring segment implantation has been approved by Medicare to correct and stabilize keratoconus. The device at issue is within the standard of care in this setting and was a medically reasonable option for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested retroactive authorization and coverage for testing for tumor necrosis factor antagonists and antibodies for evaluation of Crohn's disease. Findings: Three physician reviewers found that in this case, Anser ADA was ordered to direct the management of the patients Crohns disease.  The use of Anser ADA has not been clinically proven to improve patient clinical outcomes, and has not definitively demonstrated clinical utility.  The effectiveness of Anser ADA testing compared with conventional courses of action remains unproven.  Patients being treated with Humira may experience loss of response, but the appropriate method for determination of the cause for loss of response is not clear.  The published studies on the use of anti-adalimumab antibodies and serum levels are retrospective and/or observational in nature.  These small studies demonstrated, at best, correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect.  Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking.  Therefore, the clinical literature does not support the superior effectiveness of testing for tumor necrosis factor antagonists and antibodies over other methods of evaluation. All three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Oxycodone for treatment of her shoulder pain. The physician reviewer found that the submitted documentation fails to establish the medical necessity for the requested medication. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting 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. Moreover, Ballantyne and colleagues reported that prolonged use of high dose opiates might induce tolerance and abnormal pain sensitivity. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. Therefore, it would be in the best interest for the patient to start a multidisciplinary program. All told, the medical necessity of the requested mediation has not been established in this clinical setting. 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 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

The parent of a 17-year-old female enrollee has requested continued residential treatment services for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that the records indicate that as of the specified date, the patient was no longer a threat to herself or others. The psychiatrist and primary therapist documented that she was developing some coping skills and had insight into the nature of her problems. Therefore, she does not meet the American Academy of Child and Adolescent Psychiatry (AACAP) criteria for continued inpatient treatment. On the date indicated, the patient would have been able to safely transition to a lower level of care. Therefore, continued stay in an inpatient hospital setting from the time frame specified was not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for MRI of the thoracic and cervical spine. There is a lack of support for the requested services in this clinical setting. According to the American College of Radiology Appropriateness Criteria, new onset of cervical and thoracic spine pain should be assessed with radiographs. Additionally, computed tomography (CT) of cervical or thoracic spine may be appropriate. MRI should be used if there are new or worsening symptoms of radiculopathy or myelopathy. Per medical literatures, when patients exhibit myelopathy symptoms, such as rapidly developing muscle weakness or sensory deficit, MRI should be considered. Additionally, patients with suspected malignancy or infection involving the thoracic spine should be evaluated with a spinal MRI. In this case, the patient presented with no red flag symptoms to warrant an MRI. Therefore, MRI of the thoracic and cervical spine is not medically necessary for the 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 diagnostic radiology 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.