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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center level of care for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that documentation submitted does not support the medically necessity of the services at issue in this clinical setting. The patient had no post acute withdrawal symptoms.  The patient was not a danger to the patient or to others. The patient was not gravely disabled.  The records show that the patients activities of daily living were intact. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care.  The patient was medically and psychiatrically stable.  The patient was motivated and appeared to be working the program. The patient showed good progress in recognizing relapse triggers and improving impulse control.  The patient was compliant and was on medication-assisted treatment. The patient participated in individual, group, and family therapies.  The patient partook of other activities that the facility offered.  The patient had support systems in place.  The patient could have safely continued treatment at an ambulatory lower level of care in conjunction with a 12-step program and ongoing substance abuse counseling.  The patient no longer required 24-hour supervision at residential level of care. Therefore, the residential treatment center level of care services were not medically necessary for the 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 addiction 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

A 28-year-old female enrollee requested authorization and coverage of radiofrequency endoluminal venous closure. The health plan denied the request, indicating that the requested procedure is not medically necessary for treatment of the enrollees painful varicose veins.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: Medical Necessity
Decision: Overturned

The patient is a 15-year-old female admitted to an inpatient psychiatric treatment facility on 3/17/04 with a history of recent increasing agitation and suicidal threats. Upon admission the patient was found to have healing wounds on her forearm and claimed to have self-inflicted the wounds two weeks prior. She also made harmful threats against her mother. She was placed on suicidal watch upon admission. Her behavior prior to admission began when her mother forbade the patient from having a relationship with a man she had met on the Internet. The patient claimed she had engaged in cutting behavior on her arms and thighs for the past year and had an undisclosed overdose of her mothers medications not requiring medical attention. The patient admitted to occasional use of alcohol, but denied any other drug use. The patient also claimed to find herself too fat and engaged in food restriction and self-induced emesis a couple of times during the past year. She was treated with Prozac 20mg/day in the hospital for depression. On 3/19/04, the patient admitted that she was never suicidal, but cut herself for attention due to anger at her mother. A request has been made for reimbursement for acute inpatient psychiatric treatment services received from 3/20/04 through 3/22/04. The Health Plan has determined inpatient psychiatric treatment services were not medically necessary beyond 3/19/04.The patient was acting out in a dangerous manner necessitating acute hospitalization for safety, observation, and stabilization. Review of the submitted records reveals the patient was defiant, uncooperative, and irritable and threatened to harm herself in the hospital. Thus, there was sufficient medical necessity to justify continued hospitalization through 3/20/04 to further observe the patient and ensure her stability and safety. Therefore, I have determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 38-year-old female who is several years post gastric bypass with a reported weight loss of 100 pounds. She sought consultation with a plastic surgeon that noted prior abdominal panniculectomy for excess skin. The patient is seeking a reduction of the redundant skin and fat of her upper arms and thighs. Two plastic surgeons and her primary care provider have examined her and all suggested that no matter what procedures are proposed, the patient would need to lose additional weight first. The patients BMI at the reported weight of 220 pounds is 40.3.  The patient submitted a request for authorization of bilateral thigh lifts to her Health Plan.  The request was denied based upon a determination that the requested procedures are not medically necessary.The record provided for review includes photographs of the patient dated January 2006, a letter from the patient and medical records. There is no evidence presented in the above material that supports the medical necessity of the proposed procedures. The patients provider noted excess skin and fat deposition in the medial and lateral thigh areas and some skin maceration.  He did not document any skin problems of the degree described by the patient. The patients stated height is 62 and her weight is 220 pounds with a BMI of 40.3. Her providers appropriately encouraged additional weight reduction prior to surgical intervention.  In summary, the evidence presented leads to the conclusion that the thigh lifts are cosmetic in nature. Therefore, I have determined the requested procedures are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Xyrem for treatment of his severe narcolepsy with cataplexy.  The physician reviewer found that Xyrem is indicated for narcolepsy as well as for cataplexy. The patient has signs and symptoms of narcolepsy with cataplexy and his provider has determined that he is an excellent candidate for the use of Xyrem. There is no accepted alternative to Xyrem, and stimulant therapy would not replace the use of Xyrem. Nuvigil is considered stimulant therapy and would not replace the patients need for Xyrem. Thus, the requested Xyrem 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 sleep medicine with sub-specialty certification in pulmonary 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 53-year-old female enrollee requested right shoulder surgery (acromioplasty with rotator cuff repair) for medical  treatment of her shoulder pain.   Findings:  The physician reviewer found while a shoulder arthroscopy will not address the patients cervical issues, there is good documentation of post-fracture osteoarthritic changes at the acromion and AC joint to support a diagnosis of chronic shoulder pain with impingement syndrome. An arthroscopic intervention is therefore indicated to provide partial, but significant, benefit in management of her condition of chronic pain. The importance of the AC joint and the shape and type of downward sloping acromion or post-fracture changes within the acromion is a widely accepted finding important in shoulder pain, and in this case is a justification for shoulder arthroscopic surgery with subacromial decompression despite the lack of evidence of a rotator cuff tear on MRI. All told, the requested surgery is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old male enrollee has requested authorization and coverage for occipital nerve stimulator trial for treatment of his occipital neuralgia.  Findings:  Two physician reviewers found that occipital nerve stimulation has promise as a future therapy for neck pain and occipital neuralgia, more studies are needed to determine its safety and efficacy in patients with cervical and occipital complaints. There is insufficient evidence validating its use over more standard therapies such as medication and nerve blocks.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Nature Throid. The patient is a 57-year-old female. At an office visit, lab results showed she tested positive for thyroid antibodies, which her provider believed was due to episodic thyroid underactivity. During the visit, the patient indicated she wished to start natural thyroid hormones. She has been taking Nature Throid. The enrollee indicated her dosage has increased over a two-year period to 97.5mg. A lab report revealed her thyroid stimulating hormone was 0.39 (reference range 0.45 to 4.12) and thyroid peroxidase antibodies were 40 (reference range less than 35). A later report showed a T3 level of 2.2 (reference range 4.6 to 11.2) and thyroid peroxidase antibodies of 40. She indicates she requires a thyroid medication that includes both T3 and T4 because of her diagnosis of hypothyroid and Hashimotos thyroiditis. She is requesting coverage of Nature Thyroid. Review of the record indicates insufficient evidence of the patients trial and failure or contraindications to formulary alternatives, such as levothyroxine, levoxyl, liothyronine, Synthroid, Thyrolar and Unithroid. The medical literature describes a study that investigated the outcomes of a group of patients who were utilizing thyroid hormone extracts. The study reported adverse events. Ninety-one of these reports also showed alterations in thyrotropin values. Sixty-eight percent of the patients developed symptoms of altered thyroid-stimulating hormone, some of which were consistent with thyrotoxicosis. Two patients developed arrhythmias. Levothyroxine remains the standard of care among professional endocrine societies for treating thyroid deficiency. Dosage decisions for levothyroxine thyroid replacement require a thorough patient assessment and the review of many factors; such as age, the presence of cardiac disease, and the etiology of the patients hypothyroidism. Studies describe difficulty in dose adjustment of hormone extracts due to confusion in interpreting thyroid function test results while on thyroid extract. Standard of care and practice include replacement of T4 only, including treatment for Hashimoto Thyroiditis. The requested therapy with Nature Thyroid does not offer unique safety and efficacy advantages over other commercially available thyroid hormone preparations.  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 endocrinology, diabetes & metabolism 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

A 37-year-old male enrollee has requested Butrans (buprenorphine) for his cervicalgia, degeneration of cervical intervertebral disc, and chronic pain syndrome. Findings:  The physician reviewer found that given the lack of documentation that the patient is taking high levels of opioid medications, as well as the absence of documentation of prior opioid dependence, prior misuse, prior attempts with Duragesic, and prior attempts with morphine sulfate extended-release products, the medical necessity of Butrans is not supported.
Appeal type: Experimental/Investigational
Decision: Upheld

The mother of a 14-year-old enrollee has requested care at a residential treatment facility for the treatment of the enrollees psychiatric problems. Findings:  Two physician reviewers found that the experiential care of this particular residential treatment facility allows patients to be in the field visited by a nurse once a week.  The program did not incorporate all of the professional care this patient requires.  For this reason I do not find evidence demonstrating it is more effective than a standard residential treatment facility.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility stay including services for physical therapy, speech therapy and occupational therapy provided for treatment of the enrollee who has a history of strokes. Findings:  The physician reviewer found that functional impairments due to acquired brain insults such as meningitis, encephalopathy and non-traumatic intracerebral hemorrhage can be profound. Nevertheless, some recovery is expected with time, such as natural recovery processes. The medical studies suggest that many of these impairments are amenable or addressable by compensatory measures and directed rehabilitation efforts. The role of inpatient rehabilitative care for patients with significant functional deficits following stroke is relatively well established in the medical literature. In the present case, the patient has had multiple cerebral insults due to toxic metabolic encephalopathy, strokes and intracerebral hemorrhage. The patient has undergone extensive rehabilitation, but has made very limited gains over a prolonged period of time. She continues to be dependent for mobility and to require significant assistance for self-care. Based on her records, she has otherwise medically stabilized and does not require skilled nursing or medical services in an inpatient hospital setting. The patients needs, overall, were and are at the custodial level of care. The need for further skilled nursing facility level care is not supported by the available records. Final Result: The reviewer determined that the services at issue 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco and Lidoderm patches for treatment of the enrollees lower back pain. Findings:  The physician reviewer found that there is a lack of support for the medical necessity for the requested medications in this clinical setting. Chronic pain that has no hope for a cure is considered palliative in nature and treatment. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. However, in the documentation available for review, no objective treatment goals for pain and function are noted for the requested medications, and several requirements for opioid prescribing have not been documented.  Thus, the need to use them as the primary medication treatment strategy for pain has not been established. Additionally, it not clear what type of injections have not been helpful for her back pain. Also, other interventional procedures for treatment of pain coming from arthritic joints have not been noted. It is also unclear that this patient has initiated physical therapy for treatment of her pain symptoms. Behavior therapy is also an option for chronic pain and would help avoid medications and injections. Finally, not all medications classes have been optimized for her pain.  As such, the medical necessity for Norco and Lidoderm patches, as the next best step for pain control in the back and her arthritic joints, has not been established. 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: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested for skilled nursing facility services for treatment of her multiple sclerosis. Findings:  The physician reviewer found that therapy with occupational therapy and physical therapy are well accepted as beneficial in reducing disability, but have not been effective in this case in restoring strength or function.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cervical spine bone growth stimulator. Khalifeh and colleagues state, Pseudarthrosis is an exceedingly common, costly, and morbid complication in the treatment of long bone fractures and after spinal fusion surgery. Electrical bone growth stimulation (EBGS) presents a unique approach to accelerate healing and promote fusion success rates. Over the past three decades, increased experience and widespread use of EBGS devices has led to significant improvements in stimulation paradigms and clinical outcomes. Various models of electrical stimulation have been proposed and marketed as adjuncts for spinal fusions and long bone fractures. Clinical studies show variable safety and efficacy of EBGS under different conditions and clinical scenarios. While the results of clinical trials do not support indiscriminate EBGS utilization for any bone injury, the evidence does suggest that EBGS is desirable and cost efficient for certain orthopedic indications, especially when used in combination with standard, first-line treatments. In a systematic review of electrical stimulation to enhance spinal fusion, Park and colleagues state, Given the inconsistency in study results, possibly due to heterogeneity in study populations/characteristics and quality, we are unable to conclude that electrical stimulation results in better fusion outcomes compared with no stimulation. The overall strength of evidence for the conclusions is low. In this case, the patient was being treated for disc degeneration, spinal stenosis, and cervical myelopathy. She presented with persistent pain in the cervical spine, with numbness and tingling. X-rays showed good positioning of hardware, without loosening. However, detailed documentation is not evident regarding any significant risk factors for failed fusion. There is no documentation of significant past medical history. There is no tobacco use noted. X-rays did not denote signs of non-union or delayed union that would benefit from the requested electrical stimulation. Therefore, cervical spine bone growth stimulator is not medically necessary for the treatment of this 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 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: Experimental/Investigational
Decision: Overturned

A 62-year-old female enrollee has requested radiofrequency neurolysis for the treatment of her chronic low back pain. Findings:  Two physician reviewers found that radiofrequency neurolysis is well-documented in the treatment of chronic spinal pain. Several studies document its success (Bogduk and Dreyfuss, et al.). However, the evidence for radiofrequency neurolysis for the treatment of sacroccygeal pain is more limited (Saris). Nevertheless, this patients pain has previously been successfully treated with radiofrequency neurolysis, giving her two years of symptomatic relief. In light of the duration of her previous response as well as the lack of available treatment options in this complex setting, there is sufficient evidence to support the efficacy of repeat radiofrequency neurolysis for this particular patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS) services. Findings:  The physician reviewer found that This patient has a history of major depression and has not responded to treatment with multiple classes of antidepressants, adjunctive brexpiprazole treatment, and psychotherapy. The patients provider has recommended treatment with TMS for treatment resistant depression. Multiple randomized controlled trials have demonstrated the safety and efficacy of repetitive TMS therapy for the management of patients with severe depression non-responsive to pharmacotherapy. In addition, the U.S. Food and Drug Administration (FDA) has approved the treatment of TMS for the management of patients who have not responded to one adequate antidepressant trial in the current depressive episode (Cohen, et al.). This FDA recommendation is consistent with treatment guidelines from the American Psychiatric Association (McClintock, et al.). Based on the current guidelines, this patient meets the criteria for treatment with TMS. Moreover, the requested TMS is in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Given this support, the requested TMS services are 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 psychiatry with subspecialty certification in preventive 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.