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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly or biweekly eye movement desensitization and reprocessing (EMDR) therapy services. The records provided for review support diagnoses of depression, anxiety, and post-traumatic stress disorder (PTSD). The provider noted that the patient previously benefited from weekly treatment with EMDR focused psychotherapy. Thus, the provider has recommended additional EMDR services. As noted in the medical literature, treatment with EMDR can be effective for patients with PTSD (Westfall and Nemeroff; Watkins, et al.). Additionally, this patient has benefited from EMDR focused psychotherapy in the past, particularly with improvement in her PTSD symptoms. In this clinical setting, EMDR focused psychotherapy is appropriate to address this patients current symptomatology. EMDR, to be effective, is usually done once or twice weekly. Moreover, the requested EMDR 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 patients prior response to weekly EMDR treatment, the requested weekly EMDR 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 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 transcranial magnetic stimulation (TMS) treatment. Current medical literature supports the use of TMS as a safe and effective treatment for refractory bipolar depression. Researchers note that TMS is effective in the bipolar depressed population where episode-focused intervention can be specifically offered. In this case, visit notes reported diagnoses of bipolar depression and anxiety. The records noted that the patient endorsed passive suicidal thoughts in the past six weeks. Given this patients continued symptoms despite a documented prolonged treatment history and numerous medication trials, including electroconvulsive therapy (ECT), the requested service is likely to be more beneficial than any available standard treatment. Therefore, TMS treatment is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested transcranial magnetic stimulation (TMS) 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 services are likely to be more beneficial for treatment 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 psychiatry 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: Overturned

A 61-year-old female enrollee has requested continued treatment with testosterone pellet implantation for the treatment of her menopausal symptoms. Findings:  Two physician reviewers found that over the recent years, there is increasing evidence-based data and empirical experience by physicians and patients that androgen insufficiency is a real entity in women, particularly during the menopausal time period. Treatment with testosterone/androgen therapy, by various routes, can result in a substantial decrease in troublesome symptoms. Studies involving non-oral testosterone products are on-going, but here are currently no products with FDA approval for use in women. The use of testosterone patches and creams is not an FDA-approved alternative to testosterone pellet implantation. Nonetheless, non-oral testosterone formulations are widely used in the United States and internationally to treat androgen-deficiency syndromes in women, with excellent results and apparent safety. The current therapy has clearly provided a benefit for this patient and continued treatment is consistent with the standard of care within the gynecological community.
Appeal type: Medical Necessity
Decision: Upheld

The patient is an 19-year-old female who was admitted to residential treatment because of anorexia nervosa and depressive disorder, not otherwise specified. She had been restricting her food intake for eight months prior to admission after she broke her foot. Although she reported feeling fat and uncomfortable in her own skin for some years, she had not restricted her food intake until the foot injury. In addition to restricting her intake, the patient grew increasingly depressed, performed poorly academically and returned to living at home with her family. She received outpatient therapy but was unable to maintain a healthy weight and continued to feel depressed, and anxious with low self-esteem and poor body image. She also noted sleep continuity disturbance and low energy. During residential treatment, she was involved in a number of therapies and received both Zyprexa as well as Lexapro. She was thought to have eventually improved with both such that she was taken off the Zyprexa and left on only the Lexapro and Synthroid. The final dose of Lexapro appears to have been 10 mg and the final dose of the Synthroid .05 mg.Based upon the information submitted, the patient was making progress with her residential treatment. She had nearly attained her ideal body weight, was compliant with her medications, and was not exercising excessively. Records from September 2004 support the fact the patient was ready for transition to a less intense level of care. The evidence submitted does not demonstrate as of September 2004 the patient required 24-hour supervision or was too unstable for transfer to a less intense level of care.Based upon the information set forth above, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old female enrollee requested authorization and coverage of an extended course of intravenous Rocephin. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees Lyme disease.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 39-year-old male enrollee has requested for radiofrequency nerve ablation for treatment of his pain. Findings:  Two physician reviewers found that this patient has low back pain which appears to be related to the facet joints, as demonstrated by multiple facet joint nerve blocks.   Multiple blocks tend to reduce the false positive rate.  The accuracy of medial branch blocks for diagnostic purposes has been proven by long-term follow-up.  Per the current medical literature, there is support for the requested radiofrequency nerve ablation in this clinical setting.  In sum, the requested radiofrequency nerve ablation is likely to be more effective than other treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A forty-five year-old female who underwent bilateral prophylactic mastectomies and reconstruction with implants is requesting reimbursement of revisional breast reconstruction. Reviewers Findings:The reviewing physician found that although revision of the reconstruction was appropriate to improve the aesthetic outcome of the reconstruction, the procedure did not treat a functional problem and was not medically necessary by conventional standards.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 40-year-old female enrollee has requested a magnetoencephalography (MEG) for evaluation of her epilepsy. Findings:  Three physician reviewers found that despite a comprehensive assessment, the patients seizure source remains obscure. Although it is still a relatively new technology, MEG has shown increasing benefit in localizing epileptic lesions. It has become a generally accepted diagnostic tool at major epilepsy surgery centers because of its ability to identify deep seizure foci that escape standard EEG. MEG is also helpful when MRI scans show a lesion that is discordant from EEG findings and MEG can map critical areas of brain function to optimize surgical planning. MEG should be considered a standard tool in the non-invasive, preoperative evaluation of potential candidates for epilepsy surgery.
Appeal type: Experimental/Investigational
Decision: Overturned

A 57-year-old female enrollee has requested magnetic resonance spectroscopy (MRS) for an evaluation of her glioblastoma multiforme. Findings:  Two physician reviewers found that the use of MRS in this situation is state of the art for neurosurgical practice. It will provide vital information in this situation and will be very helpful for the patient. The denial is not appropriate, and the MRS study should be approved. Thus, the requested diagnostic procedure is likely to be more beneficial for evaluation of the enrollees medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for a power scooter. The submitted documentation does not support that the requested power scooter is medically necessary. The submitted records do not reveal that the patients mobility limitations cause him to be unable to perform activities of daily living in the home or outside of the home. A functional mobility assessment of the patient indicates that the appropriate device for the patient would be a heavy-duty four wheeled walker with a seat for his endurance deficits. The documentation does not reveal significant neurological deficits or gait abnormalities, but rather poor endurance due to obesity and COPD. In addition, records indicate that the requested power scooter would not fit inside the patients home. The patient was noted to be independent with shopping and occasionally needs help for heavy work. He has low endurance and uses oxygen at night. The records noted a gait normal distance of 50 feet, best distance of 100 feet, and worst distance of 25 feet. The documentation does not support that the patient requires a power scooter for outside the home. The patients needs could be adequately met with a heavy-duty four-wheeled walker with a seat as recommended by his provider if he experiences fatigue on longer distances. Records reflect that the patients physician is encouraging exercise, and medical literature supports physical activity, as sedentary behavior is linked to adverse health outcomes. Under these circumstances, the requested power scooter is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested durable medical equipment is not medically necessary to treat 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 subspecialty 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

The patient is a 46-year-old female who is 51 weighing 240 pounds with a body mass index (BMI) of 45. She has comorbid conditions of hypertension, asthma, and osteoarthritis. She is status post Nissen fundoplication. She has been approved for bariatric surgery on the condition that she loses weight preoperatively and attends support group meetings. She has not complied with these conditions. Based upon the information provided, she has not been evaluated by a bariatric surgeon since 2004. In addition, it is unclear when the patient underwent a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery.With a BMI of 45 and comorbid conditions the patient meets accepted criteria for consideration of weight loss surgery. However, the patient has not been evaluated by a bariatric surgeon in almost a year and it is unclear when she underwent a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery. Because of the time which has passed the patient should be re-evaluated by a bariatric surgeon and undergo a psychological evaluation. If these evaluations indicate the patient is an appropriate candidate for surgery  surgery should be authorized. If these evaluations indicate surgery is contraindicated  surgery should not be authorized.Regarding the Health Plans 10% weight loss requirement, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese. Furthermore, the report cited by the Health Plan as demonstrating benefit to preoperative weight loss refers to a preoperative weight loss of 5% not 10%.Based upon the information set forth above and because of the time which has passed the patient should be re-evaluated by a bariatric surgeon and undergo a psychological evaluation. Therefore, the Health Plans denial should be upheld at this time. If these evaluations indicate the patient is an appropriate candidate for surgery  surgery should be authorized. If these evaluations indicate surgery is contraindicated  surgery should not be authorized.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization level of care services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the progress notes indicate that the patient was cooperative in treatment.  However, she did have some difficulty engaging in group treatment. She reported substance cravings on several occasions.  The patient had depressive symptoms during her stay, but she did not display any dangerous behaviors while in the partial hospitalization program. Per the records, the patient could have received effective treatment on an intensive outpatient basis due to her lack of self-harm behaviors and lack of active suicidal or homicidal ideation.  The supplied documentation does not indicate that she was having severe mood swings or other severe psychiatric symptoms. Intensive outpatient programs allow individuals to remain in their own homes and communities, which may improve their adjustment to community life. 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 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 patient is a 35-year-old man with hyperhidrosis. The submitted information does not indicate that conservative treatment has been attempted. The patient has requested authorization for bilateral curettage of axillary dermis. The Health Plans denial is medically reasonable and appropriate. The requested surgery is not the standard of care for treatment of the patients condition. No evidence has been provided that the patient has tried and failed conservative treatment. Non-surgical measures including the use of antiperspirants should be exhausted before axillary curettage is considered. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 49-year-old male enrollee has requested for bilateral laser vitreolysis for treatment of his vitreous floaters. Findings:  Two physician reviewers found that laser vitreolysis is not a procedure practiced by the vast majority of vitreo-retinal specialists in the country. There is presently insufficient literature to establish this procedure as an efficacious modality in patients with vitreous floaters.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested anesthesia services for treatment of the enrollee, who is status post sleeve gastrectomy.  Findings: The physician reviewer found that according to the American Society of Anesthesiologists guidelines for anesthesia care during endoscopic procedures, monitored anesthesia care is warranted in prolonged or painful procedures such as polyp resections, endoscopic retrograde cholangiopancreatography or other biliary procedures, endoscopic dilation, or endoscopic resection.  Additionally, the guidelines state that monitored anesthesia care may be necessary in patients with a failed history of moderate sedation for the procedure or psychological impediments to cooperation.  The provided records do not support any of these criteria, or other criteria in the literature.  The current medical evidence does not support the services at issue in this clinical setting.  All told, anesthesia services provided during an endoscopy were not medically necessary for the treatment of this patient.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 internal medicine with sub-specialty certification in gastroenterology 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 an attended overnight polysomnography sleep study on continuous positive airway pressure (CPAP) or bi-level positive airway pressure (Bi-PAP) for evaluation of the enrollees obstructive sleep apnea (OSA). Findings:  The physician reviewer found that the use of CPAP is considered first-line treatment for patients with OSA and its use is supported across multiple practice guidelines. However, current practice guidelines do not indicate which CPAP should initially be provided via an attended titration study versus an auto-titrating device. Current literature has shown that home based attended positive airway pressure (AutoPAP) is as effective as automatic in-laboratory titrations when used as initial treatment for OSA. There is also no proven difference in comfort or compliance rates between the two approaches to treatment. In this case, the patient is not reported to have any comorbid medical conditions which would necessitate an attended titration due to respiratory problems such as congestive heart failure, chronic obstructive pulmonary disease, or neuromuscular disease. The patient should be able to undergo a home trial of AutoPAP and the performance of an attended study would therefore exceed the patients clinical needs. All told, the requested attended overnight polysomnography sleep study on CPAP or Bi-PAP is not supported as medically necessary for evaluation of this patients OSA. 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 neurology with sub-specialty certification in sleep 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 Norco for treatment of her chronic low back pain.  The physician reviewer found that the submitted documentation fails to establish the medical necessity for the requested medication. The current standard of care for chronic low back pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. Given the patient has failed to show improved function on this particular opioid and demonstrated lack of compliance with the medication, the requested medication is not medically necessary. 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 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: Urgent Care
Decision: Upheld

A 51-year-old male enrollee has requested emergency services for the treatment of his condition. Findings:  The physician reviewer found that the patient presented with an acute condition. He had an infected sebaceous cyst that undoubtedly caused him discomfort.  However, neither the pain nor the disorder was of sufficient severity that a prudent layperson would seek immediate emergency medical care.  There was no threat or jeopardy to his life or bodily organ functions.