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

A 54-year-old female enrollee has requested the medication Adderall for treatment of her behavioral health condition. Findings:  The physician reviewer found that current Food and Drug Administration guidelines indicate that Adderall is indicated for the treatment of ADHD and its use in patients with a history of substance abuse is contraindicated. The medical records submitted do not provide confirmatory evidence of a diagnosis of ADHD. The documentation in the records fairly clearly points to a diagnosis of bipolar disorder. Current American Psychiatric Association guidelines do not recommend stimulants for the condition of bipolar disorder, and in fact, they may make the manic symptoms worse. Furthermore, this patient has a well-documented history of substance abuse, including past abuse of amphetamines which contraindicates the use of stimulants. Given that an indication for the medication Adderall has not been established, and in fact it is contraindicated in this patients case, current standards of accepted medical practice do not support prescription of Adderall in this particular setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for artificial disc replacement surgery by anterior approach (CPT code 22857). The records document that this patient presents with chronic lower back pain that originates in the back, with radiation into the left buttock, posterior thigh, and posterior lateral lower extremity. Physical examination revealed antalgic gait with left lower extremity pain. The patients providers have recommended treatment with artificial disc replacement surgery by anterior approach. However, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. The available documentation includes reports of conservative measures noted on the examination. There is a lack of updated documentation of recent conservative measures, which is essential since the patient is status post-surgery at bilateral L5-S1. In addition, formal imaging studies were not provided for review to corroborate the currently noted pathology. For these reasons, the requested artificial disc replacement surgery by anterior approach (CPT code 22857) is not medically necessary for 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 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

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for speech therapy. Capone Singleton reports that a wait and see approach to delaying speech therapy services for children with developmental speech and language disorder may place late talking children who do not receive professional intervention at risk for life-long disability. Liu and colleagues explain, The ability to communicate effectively with others is central to children's development. Delays or disruptions due to isolated expressive language delay, articulation errors, multiple sound production errors with motor planning deficits, or mixed expressive and receptive language delay, often bring widespread consequences. OHare and Bremner emphasize the need for comprehensive speech and language assessment, and for speech therapy, for children with speech and language difficulty. In this case, the patient has developmental speech and language disorder. The records note at a chronological age of 31 months, the patients cognitive ability was assessed as being equivalent to 24 months. While the records note that the patient has a vocabulary of approximately 25 words, the expected vocabulary for the patient's chronological age is between 50 to 100 words. Given the patients significant expressive language delay, and as speech delays will put the patient at a definite disadvantage both socially and academically, the requested services are medically indicated. Therefore, speech therapy is 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.
Appeal type: Medical Necessity
Decision: Overturned

A 22-year-old female enrollee has requested intensive outpatient treatment for treatment of her eating disorder.  Findings:  The physician reviewer found that this patient presents with a history of bulimia nervosa and alcohol dependence. The records indicate that the patient was not at imminent risk of serious harm to her self or others and she did not have a co-occurring medical condition. Although her co-morbid substance abuse disorder did not put her at risk for withdrawal or delirium tremens (DTs) and her family was supportive and compliant with the requirements of the IOP, applying the treatment guidelines from the American Psychiatric Association (APA), this patient did meet the level of care criteria for the IOP program during the said timeframe. Specifically, the APA guidelines for treatment of bulimia nervosa show the IOP as offering the structure for a patient at risk of relapse with adequate support. For these reasons, treatment at a less restrictive level of care such as weekly outpatient therapy would likely not have provided this patient with the guidance and support found in IOP during the period under review. Accordingly, the IOP services provided have been demonstrated to be medically necessary for management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female enrollee has requested for total hip resurfacing for treatment of her osteoarthritis.  Findings:  The physician reviewer found that there is no evidence of end-stage left hip disease. Physical examination indicates a lack of terminal left hip range of motion (ROM) parameters. While there are findings consistent with degenerative joint disease, the patient does not have end-stage pathology. Nor is there documentation of attempts at conservative treatment including physical therapy, home exercise program or non-steroid anti-inflammatory drugs (NSAIDs).
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested transcranial magnetic stimulation (TMS) for treatment of his bipolar disorder and major depression.  The physician reviewer found that this patients depression is treatment resistant since multiple antidepressants and augmentation strategies had not successfully brought on remission. The American Psychiatric Association (APA) practice guidelines for treatment of depression state that the acute phase treatment may include TMS. Schutter reported that TMS had a moderate effect on patients with treatment resistant depression. George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. Avery and colleagues provided evidence that TMS is a safe and effective treatment for major depressive disorder. All told, TMS is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested therapy 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 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

The parent of a 12-year-old female enrollee requested a pediatric wheelchair (Convaid Cruiser for medical treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested equipment.   The documentation submitted for review indicates the patients activities of daily living were not dependent on the use of a wheelchair.  Given that the patient was noted to have no significant functional limitations in regards to the lower extremities and she was not using the wheelchair on a regular basis because she is ambulatory and that the proposed wheelchair is for the purpose of fatigue, feedings and behavioral modification, the medical necessity of the requested wheelchair has not been established.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a 4-year-old male enrollee requested authorization and coverage of continued speech therapy for the treatment of autism.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not 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 speech therapy twice per week for treatment of his medical condition.  Findings:  The physician reviewer found that the patient presents with anoxic encephalopathy; recovery from this type of injury, like most brain injuries, is often slow and incomplete. Therapies have been shown to be beneficial in facilitating recovery, but results can plateau. Active efforts at therapy are dependent on patient participation, which is a function of capabilities and motivation. In this patients case, the submitted records indicate that his recovery has slowed or plateaued. There is a lack of clinical documentation demonstrating that the patient was benefitting from continued therapy. In the absence of evidence that additional speech therapy is likely to result in an improved functional outcome, the medical necessity of the requested speech therapy twice per week has not been established.   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 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: The patient has requested authorization and coverage for isotretinoin.  Findings: Isotretinoin has been demonstrated to be the most effective treatment for acne vulgaris. Data suggests that treatment with isotretinoin has the potential to provide long-term improvement or remission. The American Academy of Dermatology (AAD) guidelines include isotretinoin for the treatment of acne vulgaris, especially moderate acne vulgaris that has been resistant to other treatments. This patients records document failure with at least two topical and one oral therapeutic option. They present with moderate severity of inflammatory papules as noted by the provider. Given these findings, the requested isotretinoin 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 dermatology with subspecialty certification in dermatopathology 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 enrollees parent has requested authorization and coverage for intravenous immune globulin (IVIG) with Gamunex-C. Findings: The physician reviewer found that this patients records document antibody proven autoimmune encephalitis. The condition is reported to have not responded to IV steroids and non-steroidal anti-inflammatory drugs (NSAIDs). For these reasons, the requested IVIG with Gamunex-C is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Three physician reviewers found the requested IVIG with Gamunex-C is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested IVIG with Gamunex-C is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology 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 60-year-old female enrollee has requested for a positron emission tomography (PET) scan for evaluation of her pheochromocytoma. Findings:  Two physician reviewers found that MIBG imaging is generally a well-accepted and accurate method of evaluating pheochromocytoma. A PET scan can sometimes find lesions that MIBG exam does not. The current standard of practice would be to perform the MIBG exam as the first line of imaging.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee has requested percutaneous tibial nerve stimulation for treatment of his nocturia.  Findings:  Three physician reviewers found that the etiology of lower urinary symptoms of frequency and urgency can be multifactorial in origin. The submitted documentation indicated that the patient has nocturnal polyuria. The urgency may be significantly affected by a large nocturnal urine production.  At this time, there is a lack of studies demonstrating the effectiveness of the requested services for the symptom of nocturnal polyuria. Percutaneous tibial nerve stimulation has been evaluated for urgency and other overactive bladder symptoms.  However, to date, these studies have not been evaluated over a long enough period to state its efficacy.  Therefore, the requested percutaneous tibial nerve stimulation is not likely to be of greater benefit than other available treatment options in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old male enrollee has requested for hybrid artificial disc replacement at L4-5 with interbody fusion at L5-S1 for treatment of his two-level lumbar disc disease and pain. Findings:  Three physician reviewers found that there are no compelling indications for the requested surgery in this individuals case for what appears to be axial back pain.  There is no evidence of demonstrable instability.  There is no evidence of progressive neurologic deficit.  Furthermore, artificial disc replacement remains investigational, as there are no well controlled studies that have demonstrated its efficacy, and long-term benefits remain to be determined.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old male enrollee has requested disc replacement or fusion of disc for treatment of his cervical neck and left upper extremity pain. Findings:  Three physician reviewers found that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard treatment. The medical records submitted for review fail to document that a conservative physical therapy program has been tried and failed. In addition, the properties of wear and the resultant patient response to wear debris from bearing surfaces of hip, knee and spinal disc share the same phenomenon (Flynn). Total hip and total knee replacement devices have a predictable rate of the need for revision and secondary procedures over time. Studies of longer duration are needed to assess the longer term potential complications of a methylmethacrylate arthroplasty within the cervical spine. Given the patients age and the potential for complications and lack of documented conservative care, the request for disc replacement or fusion of disc are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapies.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for a Synvisc-One (hyaluronan) injection in the left knee. The current evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. 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 when everything else has been tried and the options are limited. In this case, there is a history of substantial benefit from prior viscosupplementation with Synvisc-One. Furthermore, their options are clearly limited. The patient has tried and failed other conservative treatments with the alternative being a total knee arthroplasty. Under these circumstances, a Synvisc-One (hyaluronan) injection in the left knee is medically necessary to treat the medical condition.Final Result: The reviewer determined that the requested service 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 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 special tires (pneumatic rear wheel tires with airless inserts) for management of the enrollees medical condition. Findings: The physician reviewer found that there is a lack of medical support for the requested equipment in this clinical setting. The requested pneumatic rear wheels with airless inserts were recommended for the patient in order to decrease the maintenance needed on the tires. However, the provided records indicated that the patient lives in a residential area in a single family home. No unusual environmental conditions were presented or noted in this patients case. The patient has no communication impairment and would be expected to be able to call for assistance if she required assistance with changing a flat tire. The requested equipment is not clinically supported for the proper mechanical function of the patients wheelchair. Therefore, the requested special tires (pneumatic rear wheel tires with airless inserts) are not medically necessary for treatment of the patient.Final Result: The reviewer determined that the requested equipment 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 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: Overturned

The parent of a 15-year-old male enrollee has requested psychiatric residential treatment for the treatment of the enrollees autism spectrum disorder/pervasive developmental disorder, not otherwise specified, organic mood disorder, secondary to cerebral dysrhythmia and birth anoxia/hypoxia and attention deficit/hyperactivity disorder. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that this patient has had a long history of psychiatric issues. Physician notes demonstrate continued difficulties. The provider noted that the patient was frequently needy and required modified safety. He also noted that the patient was engaging in self-injurious behavior. His threatening and aggressive behavior continued and was directed toward self and others. A physicians note reports diminished, but continued, self-destructive, head banging behavior. The patients uncontrolled, risk-taking and dangerous behavior extended beyond the date of service in question. It is clear that the patients behavior fluctuated. However, it also clear that his level of impulsivity, recklessness and willingness to engage in running away, head banging and related activities constituted a continuing safety risk. This risk extended beyond the date of service in question and constituted a danger to the patient and also to others. It appears that the patient only gradually gained internal control. He needed 24/7 staff observation and care up to the date of discharge. Thus, psychiatric residential services were medically necessary and appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old female enrollee requested positron emission tomography (PET) scan of the brain for medical evaluation of her Parkinsons disease.   Findings:  Two physician reviewers found that there is insufficient medical literature supporting the use of a PET scan in this clinical setting. The diagnosis of Parkinson disease is mainly based on clinical criteria characterized by motor symptoms including bradykinesia, rigidity, resting tremor, and postural instability (Hsiao, et al). In this case, the provider recommended the diagnostic procedure to further confirm the patients diagnosis of Parkinsons disease. There is a lack of controlled studies supporting the use of PET scan for the diagnosis of Parkinsons disease. Therefore, based on the peer-reviewed literature and medical evidence submitted the PET scan at issue was not likely to be more beneficial than standard medical therapy.