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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for abdominoplasty to repair diastasis recti and placement of acellular dermal matrix. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The patient complains of an abdominal bulge, back and pelvic pain attributed to a documented diastasis recti of the abdomen.  Conservative management had not been documented, including the use of an abdominal binder or abdominal conditioning. In addition, work-up of other potential causes of her back and pelvic pain has not been adequately documented.  Although the patient has lower back and pelvic pain, it is not clear if abdominal muscle plication and biologic implant for reinforcement would likely correct her functional deficit of pain and weakness. The repair of diastasis recti is not generally considered to be a functional treatment, but can be an integral part to cosmetic procedures, namely abdominoplasty. Researchers noted there is some indication that muscle plication may affect intractable lower back pain.  However, the authors noted that nonoperative therapy and significant work-up for other reasons of the pain should be evaluated prior to abdominoplasty with muscle plication.  In this patients case, sufficient work-up of the pain and conservative management have not been adequately documented. 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 plastic 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 authorization and coverage for brand name Topamax 50 mg. Topiramate is a U.S. Food and Drug Administration (FDA) approved antiepileptic drug proven to reduce the frequency of seizures, migraine headache prophylaxis, and with phentermine for weight management. Topiramate has also been utilized in patients for mood, schizophrenia, psychotropic-associated weight gain, alcoholism and eating disorders. FDA bioequivalence testing ensures that the generic product performs the same as its respective brand name product. For some patients, a particular compound associated with a specific brand name medication or generic preparation is indicated. However, this patients records do not include adequate medical records with clinic progress notes documenting the patients longitudinal illness burden, relevant psychosocial stressors, and response to medication trials. All told, the requested brand name Topamax 50 mg 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 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 33-year-old male enrollee requested authorization and coverage of shoulder surgery. The Health Plan denied the request indicating that the requested surgery is not medically necessary for treatment of the enrollees shoulder injury.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: Upheld

A 19-year-old female enrollee requested intensive psychodynamic psychotherapy 4-5 times per week for medical treatment of her behavioral health condition.  Findings:  The physician reviewer found that psychodynamic therapy is not endorsed by the American Academy of Child and Adolescent Psychiatry for treatment of autism spectrum disorder, which is a highly recognizable, and often comorbid, developmental condition firmly steeped in biological etiology. The most effective treatment strategies involve behaviorally based therapies such as applied behavioral analysis. Second, the patients psychiatrist commented that the patient has just recently achieved therapeutic doses of her medication and the results have been very good. Thus, it appears that the patient has the potential to benefit from appropriate pharmacotherapy. Further, there are other standard interventions available in this setting including treatment in a multidisciplinary mental health program, which it appears was recommended for the patient earlier. Based upon the documentation provided, there is limited evidence supporting the therapeutic effectiveness of intensive psychodynamic psychotherapy in this setting and the patient has not exhausted the standard therapeutic options commonly relied upon for the treatment of her condition. As such, the requested services are not medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested authorization and coverage for gastric bypass surgery for treatment of her morbid obesity and thrombophlebitis.  Findings:  The physician reviewer found that the medical necessity of the requested surgery is has not been demonstrated in the records provided for review. This patient has not completed an updated multidisciplinary evaluation, including dietary and behavioral evaluations. In addition, there is no documentation of compliance with follow-up since her surgery in 2000. In the absence of any overt complication of the gastric bypass documented on EGD or UGI that would be improved by a revisional procedure, the medical necessity of the requested surgery is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A male enrollee requested stereotactic body radiotherapy (SBRT) for medical treatment of his prostate cancer.   Findings:  Three physician reviewers found that there is a paucity of data demonstrating that SBRT is superior to standard treatment with IMRT or image guided radiation therapy.  All told, the requested SBRT is not likely to provide this patient with an improved health outcome when compared to standard available therapies.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old male enrollee requested Otrexup (methotrexate) 25mg/0.4ml injectable for medical treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted records fail to demonstrate the medical necessity of the requested medication.  This patient has been treated appropriately with methotrexate.  He has been transitioned from oral methotrexate to subcutaneous methotrexate due to greater bioavailability, and ability to give higher doses without causing gastrointestinal distress.  There is no demonstrated medical advantage of Otrexup over generic subcutaneous methotrexate using a needle and syringe.  There is a lack of support for the requested medication in this clinical setting.  All told, the requested Otrexup (methotrexate) 25mg/0.4ml injectable is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cervical total disc arthroplasty. The submitted documentation fails to demonstrate the medical necessity of the requested services. Hybrid surgery provides equivalent outcomes and functional recovery for cervical disc diseases, and significantly better preservation of cervical range of motion compared with anterior cervical discectomy and fusion in two-year follow-up. However, more well-designed studies with large groups of patients are required to provide further evidence for the benefit and reliability of hybrid surgery for the treatment of cervical disc diseases. This patient presents with persistent neck pain radiating into the right upper extremity with numbness and tingling. She is reporting moderate functional difficulty in activities of daily living, including dropping things. Clinical examination findings have demonstrated motor and sensory deficits consistent with imaging evidence of C5/6 disc protrusion with central canal stenosis and mild cord compression. She is status post prior C6/7 anterior cervical discectomy and fusion in 2003. Under consideration is a request for an artificial disc replacement at C5/6 adjacent to the fused segment. The current medical literature indicates that large, randomized controlled trials are warranted to validate the initial findings that cervical hybrid surgery is safe and effective. There is no compelling rationale presented to support the medical necessity of total disc replacement at C5/6 over anterior cervical discectomy and fusion. Therefore, the requested cervical total disc arthroplasty is 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 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 77-year-old male enrollee has requested Pathfinder Topographic Genotyping (PTG) testing for treatment of his pancreatic cyst. Findings:  Three physician reviewers found the Pathfinder Topographic Genotyping (PTG) testing performed on a specified date was likely to be more effective for this patient than other available treatment options. In this case, the patient had a suspected pancreatic malignancy, in which the alternative to Pathfinder testing would be a more invasive surgical procedure in an attempt to rule out a negative diagnosis. Because PTG testing is supported in the peer-reviewed literature as being sufficiently reliable in the discrimination of benign and malignant lesions, its use here, as a non-invasive means of guiding future management is rational and appropriate and likely to be more beneficial than other modalities. As such, the services at issue were likely to be more beneficial than other treatment alternatives in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested a partial hospitalization program for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that per the submitted documentation, the patients condition was assessed using the Child and Adolescent Level of Care Utilization System (CALOCUS).  She was assessed in six different dimensions, ranging from risk of harm to acceptance and engagement of treatment.  In each dimension, she scored at a fairly low level of intervention, an indication that her risks of harm to self or to others were low. For these reasons, the partial hospitalization program services were not medically necessary in 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient intensive care unit (ICU) services. The records provided for review document that this patient presented with a head injury in good neurological condition. However, the patients computed tomography (CT) scan demonstrated a 0.6 cm subdural hematoma in the middle cranial fossa, scatter traumatic subarachnoid hemorrhage, and a frontal contusion. On the basis of the description of the patients presentation and imaging findings, her admission to the hospital and ICU was consistent with current medical recommendations and peer-reviewed literature. The patient required a period of careful observation and repeat imaging. Careful blood pressure control with careful titration of IV medication was indicated in the context of the patients intraparenchymal hemorrhage. Safe and adequate titration in this clinical setting cannot be performed on a floor status patient or for any meaningful period of time in the emergency department. Overall, the records support that a severe problem existed and there was an imminent need for surgery. The patient had a complex intracranial hemorrhage with a subdural, traumatic subarachnoid hemorrhage. Although the patient was in good clinical condition neurologically, careful ongoing evaluation during the first day or so after this type of injury is critical to ensure that there was no progression and a need for immediate medical intervention. The current medical literature supports that subdural hematomas, even small ones, and traumatic intraparenchymal hemorrhages can progress substantially and require surgical care. As such, hourly neurological checks are required to identify neurological decline and aid in rapid and appropriate decision making. For these reasons, the inpatient services provided were medically necessary for treatment of this patient. 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 neurological 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

A 51-year-old male enrollee has requested for cognitive rehabilitation services for treatment of his residual impairments from a stroke. Findings:  The physician reviewer found that benefit from comprehensive, community-based, cognitive rehabilitation when compared with traditional rehabilitation programs is not established and does not have support in the literature. The cognitive rehabilitation program is not superior or necessary when compared to the usual alternatives.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 16-year-old male with a history of attention deficit disorder (ADD). His ADD has been treated with Provigil since September 2004. While taking Provigil the patients academic performance improved. Prior to Provigil the patient attempted other therapies without benefit. The Health Plan has denied coverage for Provigil.The patient is benefiting from his current medication regimen. Although the evidence is still evolving, there is evidence supporting the use of Provigil in the treatment of ADD. Similar to many other medications, the off-label use of Provigil for the treatment of ADD is considered reasonable in the Pediatric community. Furthermore, because of the success the patient has had with Provigil there is no indication for him to be tried on other medication trials. Based upon the information set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested Lyrica for treatment of her back pain, neuralgia, neuritis, and radiculitis.  Findings:  The physician reviewer found that Lyrica is not medically necessary treatment for treatment of this patients chronic low back pain. Gabapentin (Neurontin) and Lyrica have similar safety and efficacy in the medical literature for chronic neuropathic pain. In the medical literature, Jeffrey published a multi-center trial including 137 spinal injury patients who were randomized to receive a flexible dose of Lyrica 150 to 600 mg per day or placebo on top of existing stable pain therapy. The purpose of the study was to assess the efficacy and safety of Lyrica in this patient population. After 12 weeks, patients in the Lyrica group had a significantly lower mean pain score than those in the placebo group. Efficacy was seen as early as the first week for some patients and was maintained through the duration of the study. The author concluded that Lyrica is being used routinely in people with neuropathic pain following spinal cord injury. Gilron reviewed the evidence-based literature supporting the use of Neurontin and Lyrica use for chronic neuropathic and early post-surgical pain. The author found that multiple, large, high quality trials have demonstrated the safety and efficacy of Neurontin and Lyrica in neuropathic pain. The review concluded that Neurontin and Lyrica are efficacious treatments for neuropathic and post-surgical pain. This patients medical records document a negative straight leg raise on physical exam and she does not seem to be exhibiting neuropathic or radicular pain. In addition, there is a lack of documentation that the patient has failed treatment with other anticonvulsant medications in the same class. Based on these findings, the requested Lyrica is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee has requested Supartz injection to the knee for the treatment of her bilateral knee arthritis. Findings:  The physician reviewer found that this patient has a history of advanced degenerative disease of both knees. She has received viscosupplementation therapy in the past with reasonable relief of her knee discomfort. Viscosupplementation has a low-risk profile. The patients morbid obesity places her at a higher than normal risk of side effects with the ongoing use of NSAIDs. Intraarticular steroids, another option in this setting, have a different mechanism of action and are more effective in a knee with an acute effusion. In addition, intraarticular steroids can have some systemic effect, and should be avoided in patients with comorbidities. Based on the patients previous positive response to viscosupplementation and her lack of complications from this therapy, the request for treatment with Supartz is medically appropriate and indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 12 physical therapy sessions for treatment of the enrollees shoulder pain. Findings:  The physician reviewer found that although PT is an appropriate initial approach for this patients shoulder diagnosis, the goal of therapy is to transition to an independent home exercise program without continued dependence on supervised therapy. The additional requested PT is not accepted as effective therapy for this patients condition. The documentation does not indicate that prior PT has resulted in significant objective increase in overall function. Thus, the 12 requested additional PT sessions do not need to be under the supervision of a therapist. The patient has had extensive prior PT and should be well versed in a home exercise program. The expected rehabilitation potential is not significant in relation to the extent and duration of PT services requested. The specialized skill of a qualified therapist is not required to establish, design and/or deliver a maintenance program to maintain the patients current condition or to prevent or slow further deterioration. Given these findings, the requested 12 PT sessions are not supported as medically necessary for treatment of this patients medical condition. 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for residential therapy treatment services for 12 months for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that based on the documentation submitted for review, residential therapy treatment services are not medically necessary for treatment of the patients medical condition. In this case, the patient presents with anxiety, depression and school problems. According to the therapy notes submitted for review, the patient has responded well to her current treatment plan which includes cognitive behavioral therapy, medication management, anxiety group therapy, family therapy and individual therapy. The patient has developed coping skills and has been able to utilize those skills during her panic attacks. Thus, residential therapy treatment is not clinically indicated for this patient given that she has successfully developed and practiced coping skills. Therefore, the requested services are not medically necessary for treatment of the patients medical condition. 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 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.