Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

A 45-year-old female has requested transcranial magnetic stimulation (TMS) therapy for treatment of her depression.   Findings:  Three physician reviewers found that the patient has a major depressive disorder, recurrent, severe.  She presents with depressed mood, lack of motivation, fatigue, problematic concentration and recent suicidal ideation. She has impaired functioning socially and occupationally. She has been tried on and failed to achieve significant improvement or remission on multiple antidepressants and augmentation strategies, including fluoxetine, Celexa, Duloxetine, Abilify, Seroquel, and Lithium, which have been either ineffective or produced intolerable side effects. Psychotherapeutic approaches have also yielded inadequate therapeutic effect.  According to the records provided for review, this patients depression is treatment resistant since multiple antidepressants and augmentation strategies have not successfully brought on remission. In the peer-reviewed studies, Schutter reported that TMS had a moderate effect on patients with treatment resistant depression. Similarly, George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. With regard to this patients diagnosis, Avery and colleagues demonstrated that TMS is a safe and effective treatment for major depressive disorder. Moreover, the American Psychiatric Association (APA) practice guidelines for treatment of depression suggest that acute phase treatment may include TMS.Thus, TMS is an effective treatment supported by the evidence-based literature. Further, TMS is widely practiced throughout the U.S., has been granted a category I CPT code by the American Medical Association (AMA), and is FDA approved for patients with treatment-resistant major depressive disorder. Consistent with this support, the requested TMS therapy will likely be more beneficial for treatment of the patients medical condition than any available modality for this patients depression.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc One hyaluronan injection in the left knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of beneficial response to viscosupplementation of the left knee and she has expressed interest in treatment with a repeated Synvisc One injection. In addition, the medical records document that the patient has failed treatment with cortisone injections and NSAIDs. Given these findings, the requested Synvisc One hyaluronan injection in the left knee 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 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

An 18-year-old male enrollee has requested a custom knee brace for treatment of his medical condition status post anterior cruciate ligament (ACL) reconstruction. Findings:  The physician reviewer found that given this patients plan to return to cutting, twisting and pivoting sports, his providers decision to provide a custom orthotic or ACL brace was clinically appropriate. Although the general use of orthotics after ACL reconstruction remains controversial, this patients provider noted specific reasons for the use of a custom brace instead of a standard device. The authors suggested the conclusions of their skiers can be generalized to other sports involving cutting, twisting and pivoting. Considering that this patient was to return to sports with similar movements as the skiers, (Sterett, et al.), the rationale for this providers approach in prescribing a custom orthotic for his patient was reasonable. In Wright and Fetzer, the authors reviewed 12 randomized controlled trials and found varying accounts on whether pain, range of motion, graft stability or protection from subsequent injury were affected by brace use. However, in the article authored by Sterett and colleagues, a total of 820 skiers who had had ACL reconstruction were divided into a cohort that used functional knee bracing during skiing. The non-braced skiers were found to be 2.74 times more likely to suffer subsequent injury than braced skiers. . In summary, the custom orthotic was in the best interest of the patients recovery and it was therefore medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a thoracic epidural steroid injection for treatment of the enrollees pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient has multiple medical problems, including chronic pancreatitis, celiac plexus syndrome, and thoracic back pain. The clinical records included a notation of a pinched thoracic nerve root as well as disc herniation at L5-S1. There is no notation of thoracic radiculopathy. The records noted a possibility of discitis of the thoracic levels identified, which would be a contraindication to performance of epidural steroid injection into the thoracic levels. Manchikanti and colleagues noted thoracic epidural injections are recommended for thoracic discogenic, disc-related, post surgery syndrome or spinal stenosis pain with fair albeit rather weak evidence. The current medical evidence does not support the requested services in this clinical setting.  All told, the requested thoracic epidural steroid injection is not medically necessary for the treatment of this patient.Final Result: The reviewers 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 physician 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: Overturned

A 38-year-old male enrollee requested authorization and coverage of reduction mammaplasty and panniculectomy for the treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested procedures are not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested procedures are medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 53-year-old woman who was diagnosed with ductal carcinoma in situ of her right breast approximately eight years ago. The patient was treated with surgery and radiation. Presumably unrelated to that, she was then diagnosed with metaplastic breast carcinoma of the left breast in 2001 and received conventional treatment for breast cancer. In early 2003, a solitary area of metastasis was discovered in the patients lung. This was felt to be recurrent metaplastic carcinoma. The patient was then treated with chemotherapy with good response. In October 2003, the patient underwent surgical excision of the metastasis, followed by two additional cycles of chemotherapy. Since that time, the patient has not had any evidence of any further metastasis or recurrence of this cancer. A recent PET scan was negative. In February 2004, the patient was placed on oral Celebrex and doxycycline as potential antiangiogenic agents to prevent further recurrence. The Health Plan has denied authorization and coverage for Celebrex on the basis that it is not medically necessary.Celebrex, which is marketed as an anti-inflammatory drug, inhibits the COX-2 enzyme, which is important in prostaglandin production. There is increasing interest in its use in cancer, as many cancers do over-express this enzyme. There is some evidence that Celebrex can reduce the number of colonic polyps developing in patients with familial adenomatous polyposis. However, there is no data as yet as to what impact this finding might have on the eventual development of cancer. There is also some evidence in mice that Celebrex might prevent the development of mammary tumors in HER2 positive mice. There are ongoing human trials looking at the incorporation of Celebrex with conventional cancer protocols. However, there is no data demonstrating the value of Celebrex in the treatment of human breast cancer. Though the patient has a rare type of breast cancer about which not much is known, conventional chemotherapy has had a good effect on the patients tumor suggesting that it responds in ways similar to more typical breast cancer. There is no evidence to support the use of Celebrex in this situation.Based upon the information set forth above, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) of the bilateral breasts for evaluation of the enrollees abnormal mammogram. Findings: The physician reviewer found that this patient has dense tissue on mammography which limits the sensitivity of mammography. However, the presence of suspicious calcifications is not to be addressed by further imaging but with stereotactic biopsy. There are no findings on MRI which can rule out ductal carcinoma in situ (DCIS) and the presence of suspicious calcifications raises the concern of that possible diagnosis. If the calcifications turn out to be malignant, an MRI may be indicated for evaluation prior to lumpectomy due to the dense mammographic breast tissue. All told, the requested MRI of the bilateral breasts is not supported as medically necessary for evaluation of this patients breast suspicious calcifications.Final Result: The reviewer determined that the requested diagnostic procedure is 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Latuda, 80 mg, quantity 105, being titrated up to 240 mg. Based on the clinical documentation provided, the patients diagnoses may include bipolar disorder with treatment-resistant depression, or schizoaffective disorder. The provider has diagnosed the patient with a bipolar spectrum illness, which supports treatment with a mood stabilizer, especially considering the patients residual symptoms are mood instability and anxiety. The patient is on Seroquel at a low dose, from which she has previously benefited. Concomitant treatment with multiple atypical antipsychotics is not recommended outside of a scenario of treatment-resistant schizophrenia in patients unable to tolerate clozapine. The U.S. Food and Drug Administration (FDA) has approved Latuda with a maximum dose of 160 mg daily Overall, the medical literature supports treatment with Latuda at a ceiling dose of 160 mg daily, which has been approved by the Health Plan. The records do not support an indication for Latuda dosed above the recommended maximum dose of 160 mg daily. Moreover, the requested Latuda dosing is not in accordance with the generally accepted standards of mental health and substance use disorder care or clinically appropriate in terms of frequency. For these reasons, the requested Latuda 80 mg, quantity 105, being titrated up to 240 mg, is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication dosage 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 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 15-year-old male has requested coverage for past inpatient psychiatric hospitalization level of care services provided for treatment of his behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, acute psychiatric hospitalization for this acutely distressed young patient was indicated and consistent with the treatment guidelines from the American Psychiatric Association (APA). However, discharge on the date at issue would have been safe and reasonable as the desired end state of acute psychiatric care is the prompt transition back to the community setting where treatment gains can be optimized. On review of the medical records, the patient had unremarkable aggression and suicide risk assessments on the date at issue. He was adherent with his atypical antipsychotic medication, and a common sedating medication was added at nighttime. He also participated in group and had a positive affect while the psychiatrist noted he was generally in better spirits with a reassuring mental status examination negative for any suicidality, homicidal thoughts or cognitive impairment. Thus, the services at issue were no longer medically necessary for treatment of the patients medical condition as of the date at issue.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary: This is a patient that is experiencing symptoms of psoriasis and psoriatic arthritis. The patient experiences skin flares on 40% of the body and joint pain in the knees, elbows and shoulders. The provider states the patient has tried and failed clobestasol, Lidex, triamcinolone, Protopic, fluocinolone, Benadryl, certirizine, Eucerin, and Cetaphil without significant improvement and continues to have skin involvement, pain and itching despite current treatment with topical medications. The patient is also receiving photo therapy. The provider is requesting the Humira pen because the benefits outweigh the risks. The provider states that medications such as methotrexate, cyclosporine or acitretin are unsafe for this patient with hypertension, type 2 diabetes, hyperlipidemia, cataracts, and anemia as symptom control will require increasing doses which would put this patient at increased risk of toxicities and adverse effects. At issue is whether the Humira pen for psoriasis/psoriatic arthritis is medically necessary to treat the patients medical condition. The submitted documentation supports the medical necessity for use of the Humira pen for this patient. The options of methotrexate, cyclosporine, or acitretin are not medically appropriate for this patient. Methotrexate would be contraindicated due to the patients history of anemia which can be exacerbated with methotrexate. Cyclosporine would be contraindicated due to the patients history of hypertension. And, acitretin would be contraindicated due to the patients history of hyperlipidemia. Therefore, the Humira pen is medically necessary to treat the patients medical condition. 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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent enrollee has requested inpatient psychiatric hospitalization services for treatment of the enrollees anxiety, depression, and an eating disorder.  The records indicate that this patient did not meet the criteria for inpatient psychiatric hospitalization services. The patient did not exhibit any suicidal or homicidal ideation, evidence of psychosis, or any symptoms of psychiatric illness severe enough to require inpatient care that could not have been reasonably be provided at a less intrusive, less invasive level of care such as partial hospitalization program (PHP). In a progress note, it was noted that the patient ate 100% of her meals and snacks, had an overall mood of three out of 10, anxiety of five out of 10, and denied urges to self-harm and denied auditory and visual hallucinations. The patient weighed just over 100 pounds. The patient denied side effects on Prozac. The patients body mass index (BMI) was approximately 20. In another note, it was noted her mood improved to six out of 10 and anxiety improved to four out of 10. Prozac was increased. It was noted that she appeared less depressed and anxious and it was noted she was eating much better than she had been at home. It was noted that the patient is planned for transition to PHP. The patient reported feeling different due to psychiatric testing. The patient requested psychological testing be discontinued due to the stress from nature of experience. The provider noted that the patient did not anticipate she would experience suicidal ideation and her mood was six out of 10, anxiety was four out of 10, and the patient denied suicidal ideation and self-injurious behaviors. The patients Prozac was decreased due to increased headaches. Given these findings, the inpatient psychiatric hospitalization services provided were not medically necessary for treatment of this patients medical condition.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 psychiatry with sub-specialty certification in child and adolescent 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for consolidation therapy (durvalumab) every two weeks for one year for treatment of the enrollees squamous cell carcinoma of lung. Findings:  Three physician reviewers found that durvalumab is one of a newer class of drugs, programmed death-ligand 1 (PDL-1) inhibitors. It was approved for use in metastatic urothelial carcinoma. However, a recent randomized study strongly suggested its efficacy as therapy post chemotherapy in non-small cell lung cancer. In that study of approximately 700 patients, all of whom had non-small cell lung cancer, had received chemotherapy, and their disease had not progressed. The participants were randomized to either have consolidation durvalumab or placebo. The median progression free survival of patients on durvalumab was 16.8 months, versus 5.6 months on placebo. At 18 months, 72.8% of patients on durvalumab had not progressed, versus 46.8 % on placebo. The development of distant metastases was 23 months on durvalumab versus 15 months on placebo. The conclusion was that the use of durvalumab in this situation was of significant clinical benefit. This use of durvalumab has been adopted by the National Comprehensive Cancer Network guidelines. As such, the medical evidence demonstrates a clinical benefit in patients who are treated with durvalumab as maintenance therapy. For these reasons, consolidation therapy (durvalumab) every two weeks for one year is likely to be more efficacious than the available standard therapy for the treatment of this patients medical condition.Final Result: The reviewers determined that the requested medication is 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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.