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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of mometasone furoate 50 mcg spray pump for treatment of the enrollee who has history of allergic rhinitis.Findings:  The physician reviewer found that according to the progress notes and the prior authorization form from the provider, the patient has symptoms consistent with chronic sinusitis and allergic rhinitis.   On the other hand, the patient has tried the requested medication mometasone furoate (Nasonex) and achieved good symptom control with minimal adverse reaction. Therefore, mometasone furoate 50 mcg spray pump is medically necessary for treatment of this patients medical condition. 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 allergy and immunology 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: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested three dimensional (3D) breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Three reviewers found that while there is a lack of long-term studies demonstrating increased survival rates correlated with the use of digital breast tomosynthesis as a part of screening mammography, recent data have shown great promise of the technique due to a decrease in repeated imaging and an increase in the detection of small cancers. The technique has been particularly useful in cases of very dense breast tissue where the utility of standard digital mammography alone is limited. All told, the use of digital breast tomosynthesis in this patient was likely to have been more beneficial than standard screening mammography alone. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Orthovisc injections in the left knee. The enrollee has left knee and low back pain. He describes his knee pain as a constant sharp, shooting, aching sensation; often associated with morning stiffness. The provider has discussed left knee replacement, but the enrollee wants to trial knee injections prior to proceeding with surgery. He reports better management of his pain with his current medications of oxycodone, 30 milligrams five times per day, and oxymorphone, 40 milligrams three times per day. A pain management progress note described the examination of the left knee as demonstrating full range of motion, crepitus, and a grossly stable medial joint line; tender to palpation. The provider is requesting Monovisc for this enrollee. Literature describes clinical studies which show hyaluronic acid injections are effective for pain relief in knee osteoarthritis. Hyaluronic acid injections improve both pain and function, and minimize the use the use of anti-inflammatory treatment and corticosteroids. Individuals tolerate the injection well, with a low rate of complications. Researchers studied previous systematic reviews of hyaluronic acid injections, and discovered the benefit of hyaluronic acid injections is underestimated analyzed conventionally methods. When accounting for control group effects studies show hyaluronic acid injections may be beneficial for a large number of those with knee osteoarthritis. A recent progress note shows the enrollee had Orthovisc injections twice prior, and the enrollee reported a greater than 65 percent relief of his pain for approximately six months following the injection. Since the enrollee has achieved symptom relief with prior treatments, it would be appropriate and necessary to repeat the hyaluronic acid injections.Final Result: The reviewer determined that the requested service is 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

The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in addiction 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: Overturned

A 64-year-old male enrollee has requested surgical implantation of a bone anchored hearing aid (BAHA) for treatment of his hearing loss.   Findings:  The physician reviewer found that the BAHA is indicated for use in patients with hearing loss who cannot tolerate the use of a conventional amplification device. In the past, this was often interpreted to mean patients with external or middle ear disease that precluded the use of traditional hearing aids. Over the years, the use of this device has been expanded to include patients with severe unilateral sensorineural hearing loss. It has been found that there is a reduction in head-shadow effect and enhancement of speech recognition with the use of a device that routes sounds from a hearing impaired ear to a contralateral normal or lesser impaired ear. Both the BAHA and the contralateral-routing of signal (CROS) hearing aid accomplish this. While there have been some recent study results which indicate that patients prefer the BAHA over the CROS hearing aid, objective data in this regard is not yet conclusive. As this patient has had a long-term trial of external hearing amplification and no longer finds it effective, the likelihood that he will benefit from the use of a CROS hearing aid is minimal. At this time, the BAHA is the best option for this patient. Given the current literature, it is most likely that with a bit more time and study, use of the BAHA will become the standard of care for patients such as this.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old female enrollee has requested a Computed Tomography (CT) scan for the evaluation of her condition. Findings:  The physician reviewer found that a CT of this patients structures was not unreasonable. Although lipomas are benign entities, they can grow and invade nearby structures. Given that this patient was symptomatic, understanding the size and depth of the lesion was advisable and constituted good medical practice.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old male enrollee requested four additional weeks of the medication combination Sovaldi and Olysio for a total of 12 weeks for treatment of his hepatitis C. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication quantity.  The current recommendations support 12 weeks of combined therapy with the combination of Sovaldi and Olysio.  The data does not demonstrate that the shortened regimen of eight weeks of Sovaldi and Olysio will be equally efficacious.  All told, the requested four additional weeks of the medication combination Sovaldi and Olysio for a total of 12 weeks is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program services for treatment of the enrollees behavioral health conditions. Findings: The physician reviewer found that according to the American Society of Addiction Medicine (ASAM), placement should be based on a complex, individual, clinical assessment rather than reimbursement limitations, program ideology, or utilization reviewers. Further, the American Psychiatric Association (APA) noted that IOP treatment that graduates used fewer psychiatric inpatient bed days in comparison with both program non-completers and their own prior use. In this case, the patients substance use disorder dominated all elements of his functionality and was complicated by anxiety and affective illness. Despite his tenuous sobriety, he remained symptomatic with depressive symptoms and anxiety. The patient was prescribed complex pharmacotherapy including a mood stabilizer with divalproex, anti-depressant with bupropion, anxiolytic with buspirone, anti-hypertensive often used for nightmares and hyperarousal with prazosin and an anti-psychotic with aripiprazole. He had been using many substances including fentanyl which is a synthetic opioid 100 times more potent than morphine. He had a serious overdose that reportedly required a reversal agent. The patient was tired, unmotivated and depressed. His provider recommended specialty care at the IOP level of care. His fledgling sobriety is jeopardized by his addictive disease, psychiatric illness burden, personality organization, and external stressors. He will more than likely relapse in the absence of IOP programming until he consolidates the treatment gains necessary to succeed independently in the outpatient setting. Considering the relevant peer-reviewed literature, current practice guidelines and the case in its entirety, service at the IOP level of care is safe, appropriate and consistent with good medical practice, and reasonably expected to improve the patients condition, bolster relapse prevention efforts and prevent a more serious episode of illness. Final Result: The reviewer determined that the services at issue were and 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 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: An enrollee has requested authorization and coverage for prescription refills of oxycodone IR 5 mg and morphine ER 15 mg for treatment of the enrollees chronic pain syndrome, thoracic vertebral fracture, and back pain with radiculopathy. Findings:  The physician reviewer found that as noted in the medical literature, chronic pain that has no hope for a cure is considered palliative in nature. The step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. However, given the documentation of this patients known history of psychiatric conditions, any continuation of such medication should be under the direct guidance of a mental health professional. It is also appropriate for the provider to consider alternatives to opioids and to wean the patient to a lower dose of opioids or even off opioids. All told, the requested prescription refills of oxycodone IR 5 mg and morphine ER 15 mg are not medically necessary for treatment of the patients medical condition. 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Anser IFX testing for evaluation of his Crohns disease.  Findings:  Three physician reviewers found that it has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. Generally, diminished or suboptimal response to infliximab or adalimumab can be managed in several ways such as shortening the interval between doses, increasing the dose, switching to a different anti-tumor necrosis factor (TNF) agent or switching to a non-anti-TNF agent based on clinical observation in lieu of Anser testing. All told, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the testing at issue was 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. All three 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 reimbursement for Otezla 30 mg tablet. Findings:  The physician reviewer found that the patient presents with a history of chronic plaque psoriasis. The patient has tried and failed therapy with ultraviolet light, topical steroids and injectable methotrexate. However, there is no documentation as to failure of a treatment trial, intolerance or contraindication to the use of the preferred formulary agents, including Enbrel, Humira, or Stelara. As there are other effective, preferred agents on the patients formulary for the treatment of psoriasis, the requested Otezla is not supported as medically necessary for treatment of this patients medical condition. 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 dermatology 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 two uninterrupted cycles of residential treatment center services (one cycle is 28 days). The documentation does not support the medical necessity of residential placement at this time. Modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment. In this case, the patient has a history of emotional dysregulation during level of care transitions. Per the records, the patient expressed suicidal ideation in the absence of an acute psychiatric syndrome only after being notified that the request for ongoing residential treatment was denied. Aside from a letter and self-report rating scale, the case file did not include records from the residential program including documents critical to the determination process, such as a psychiatric evaluation, psychosocial assessment, interpretative summary, physician narrative, multidisciplinary treatment plan or progress notes.  There was no evidence to suggest that comprehensive, evidence-based services provided in a less restrictive treatment setting would be unsafe, insufficient or inadequate. Thus, the requested two uninterrupted cycles of residential treatment center services (one cycle is 28 days) are not medically necessary 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lumbar/sacral facet joint block injection. Findings:  The physician reviewer found that the effectiveness of lumbar medial branch blocks and facet joint injections. The authors reported that, The higher responder rates in the treatment groups suggest a hypothesis that facet blocks might provide prognostic value before radiofrequency ablation. Another review published by Manchikanti and colleagues stated that, the evidence for lumbar facet joint nerve blocks using local anesthetics with or without steroid for managing chronic low back pain of facet joint origin is fair to good for short- and long-term improvement. The authors found that the best evidence for the use of medial branch blocks is for diagnostic purposes leading to a radiofrequency ablation procedure. In this case, the patient has chronic low back pain which is not radiating into the lower extremities. Previous treatment has included lumbar radiofrequency ablation with six months of low back pain relief. The provider has recommended a lumbar medial branch block to test for radiofrequency ablation procedure pending lumbar magnetic resonance imaging (MRI) results. The current literature recommends lumbar medial branch blocks to test for facetogenic low back pain, and to determine whether the patient is a candidate for treatment with radiofrequency ablation procedure. Based on the available medical records for review and the current evidence based literature, the requested lumbar/sacral facet joint block injection (CPT 64495) is medically necessary for 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 anesthesiology with subspecialty 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: Experimental/Investigational
Decision: Upheld

A 50-year-old female enrollee has requested authorization and coverage for sclerotherapy and echo guide for biopsy.  The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees varicose veins.  Findings:  Three physician reviewers found that
Appeal type: Medical Necessity
Decision: Upheld

A 21-year-old male enrollee has requested residential treatment services for treatment of his behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, this patient did not require residential level of care during the period at issue due to the fact that he was not suicidal, homicidal or psychotic. The patient also reportedly did not show any signs or symptoms of withdrawal or other medical problems that would have required a more intensive level of care. There is also no indication that the patient attempted treatment at a lower level of care prior to being admitted to the residential treatment program. The patient is noted to have a dual diagnosis that would require a combined outpatient program with psychiatric supervision and participation. Applying the practice guidelines from the American Psychiatric Association (APA) and the American Society of Addiction Medicine (ASAM), the patient could have been managed in less restrictive level of care in lieu of the residential services provided. As such, the residential treatment services provided during the said time frame has not been established as medically necessary.