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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for individual weekly psychotherapy for treatment of the enrollees depression and trauma. Findings:  The physician reviewer found that effective psychotherapy is a trusted intervention in the treatment armamentarium for patients afflicted with major depressive disorder. Current practice is focused on aggressive treatment of depression, particularly in the acute phase of the illness in which multiple sessions per week may be indicated, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery. Individual psychotherapy is a standard treatment intervention of major depressive disorder, and a brief course of individual psychotherapy is warranted in this patients case. Such treatment could help build a therapeutic rapport by capitalizing on the principles of patient centricity, prepare the patient for a transition to the group setting and/or community programming, and facilitate additional evaluation for consideration of other treatments, such as cognitive behavioral therapy for pain, trauma-focused therapy or dialectical behavioral therapy. The American Psychiatric Association (APA) suggests that time-limited brief psychotherapies may mobilize many depressed patients to more rapid improvement. In addition, the provider should carefully and systematically monitor the patients response to treatment, which can be facilitated by the use of provider and patient rated scales at regular intervals. If eight weeks of treatment does not yield at least moderate improvement with 20% or greater diminution in symptoms, the provider should thoroughly review and reappraise the treatment plan. As such, a course of eight individual therapy appointments delivered once a week over a span of eight weeks with systematic monitoring and re-assessment of the patients clinical needs upon conclusion of the treatment episode would be safe, appropriate and reasonably expected to improve the patients condition and prevent a more serious episode of illness. Accordingly, a portion of the requested services are supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A forty-five year-old male with hydronephrosis is requesting authorization and coverage of a referral for a surgical consultation.Reviewers Findings:  The reviewing physician found that the requested referral is not medically necessary for the patients condition.  The Health Plan denial was upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc One injection in the right knee. The submitted documentation supports the medical necessity of the requested services. This patient presents with significantly symptomatic right knee osteoarthritis. Functional limitations are documented in walking. Clinical examination findings are consistent with weight-bearing x-ray findings of moderate tricompartmental osteoarthritis, worse in the medial compartment. The patient has failed to adequately respond to activity modification, oral and topical medications, and corticosteroid injections. A trial of viscosupplementation is recommended to potentially delay total knee replacement surgery. The evidence-based literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and has been demonstrated to be more effective than corticosteroid injections. Therefore, the requested Synvisc One injection in the right knee is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the Njx Platelet Plasma provided. Findings:  The physician reviewer found that there is a lack of evidence to support the efficacy of platelet rich plasma for pain attributed to rotator cuff tendinopathy and as a consequence, platelet rich plasma injection is not included in any evidence based treatment algorithms. Moreover, there is a paucity of prospective controlled trials demonstrating the efficacy of platelet rich plasma in patients with partial thickness rotator cuff tears. Meta-analysis of trials of platelet rich plasma injection as an adjunct to healing following repair of more severe full thickness rotator cuff tears has failed to demonstrate efficacy. Thus, the Njx Platelet Plasma provided not likely to be more beneficial for the patients left shoulder pain than available standard treatment.Final Result: The reviewers determined that the service at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1,2 & 3 are board certified in orthopedic surgery 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: Medical Necessity
Decision: Upheld

A 22-year-old male has requested foot orthotics for treatment of his acquired flat foot.  Findings:  The physician reviewer found that review of the submitted information demonstrates that the requested orthotics are not medically necessary for treatment of the patients medical condition. Orthotic therapy has been shown to be very successful for a multitude of foot pathologies. In this patients case, there is no evidence of a detailed physical examination in the documentation provided. Other than a diagnosis of acquired flat foot, there are no specifics as to this patient's faulty foot biomechanics. Feet are dynamic and change over time. In the absence of an in-depth physical exam, the medical necessity of the patients continued use of orthotics is not established. The submitted evidence does not demonstrate the patient meets accepted clinical indications for the use of orthotics such as foot disfigurement, diabetes or developmental abnormality. The medical record documentation does not reveal any evidence of these pathologies.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested for the medication Provigil for treatment of her depression. Findings:  The physician reviewer found that there is no valid research establishing that Provigil is clinically effective in treating hypersomnia/insomnia or depressive symptoms in patients with a primary diagnosis of major depression. One study cited by the provider indicated that there was no significant difference in the mean reduction of Fatigue Severity Scale (FSS) scores and Brief Fatigue Inventory (BFI) scores between the placebo and Provigil groups. The other study cited  was for patients with bipolar depression. Provigil it is not considered a standard medication for the relief of depressive symptoms and there are other more conventional medications available to the patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a six-year-old male enrollee has requested audiology testingfor evaluation of the enrollee, who reportedly has difficulty hearing. Findings:  The physician reviewer found that the patient has modest inattention and impulsivity which would suggest some degree of attention deficit disorder.  CAPD is a diagnosis made by an audiologists electrophysiological tests.  There is a lack of medical evidence supporting the requested testing.  Research in this area has been marred by frequent design and descriptive flaws which suggest that validating CAPD is extremely difficult.  There are many etiologies that may be associated with CAPD, again clouding the ability to make the diagnosis (Bamiou and colleagues).  Ferguson and colleagues suggested that what is described as CAPD is actually a specific language disorder.  Thus, the limited peer-reviewed papers raise doubt as to the validity of the diagnosis and the value of therapy directed following the diagnosis.  All told, the requested diagnostic testing is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested frontal bone lesion removal surgery for treatment of his medical condition. Findings:  The physician reviewer found that according to the peer-reviewed literature, in this clinical setting indications for surgery include a rapidly growing lesion or one that occludes/obstructs the sinonasal drainage system (Ehieli, et al; Turri-Zanoni, et al). According to Turri-Zanoni and colleagues a wait and scan policy is the therapeutic standard. In this case, the patient presents with an incidental, benign appearing left frontal skull lesion. There is no surrounding reaction to the lesion. Moreover, the lesion has not increased in size as noted on successive radiographic studies. In addition, the lesion has not obstructed the sinonasal drainage system. All told, 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 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: Overturned

A 58-year-old female enrollee has requested authorization and coverage for Tysabri for treatment of multiple sclerosis. Findings:  The physician reviewer found that this patient has MS with noted weakness, imbalance, stiffness and spasticity. The detailed consult note from the patients treating neurologist states that the patient has a primarily relapsing physiology in regards to her MS. The patient has failed treatment with prednisone and Cellcept. The Health Plan has denied treatment with Tysabi because the patient has not attempted trials with interferon or Copaxone. The available medical literature indicates that Tysabri is as effective for the treatment of MS as interferon or Copaxone. Additionally, the prescribing information indicates that treatment with Tysabri carries a lower risk of heart related complications than the other suggested medications. In sum, the medication Tysabri is appropriate for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 46-year-old female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees pain.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for an inpatient hospital stay. The Health Plan denied the inpatient hospital stay as not medically necessary for the patients medical condition. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the requested inpatient hospital stay on the date in question. In this case, the patient was admitted in stable condition for a scheduled surgery.  He improved clinically without any complications. By the date in question, the patients vital signs were stable, physical exam unremarkable, and his pain was noted as being well-controlled.  He had a Foley catheter for voiding; was ambulating and could have been treated at a lower level of care. The additional medical documentation includes the admitting history and physical, operative report, discharge instructions, and progress notes. On the date in question, the patient was still having pain and passing flatus without a rating on VAS (visual analogue scale), but with stable vital signs and lab studies. A physical examination was unremarkable. Ambulation and oral analgesics as needed continued. Therefore, the inpatient hospital stay for this date was not medically necessary for the patient.Final Result: The reviewer determined that the inpatient hospital stay for the date in question was not medically necessary for the patient and the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal 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: The patient has requested authorization and coverage for physical therapy for the neck including traction, physical therapy for the right hip including traction, and physical therapy for the right shoulder. Findings:  The physician reviewer found that  records provided for review document that this patient has experienced chronic, widespread pain complaints that do not correlate well with her injury history or physical examination findings. She has undergone treatment with physical therapy without significant benefit. The records suggest that independent exercises and modalities are appropriate for this patient. While the patient has chronic symptoms, no marginal difference in clinical outcome is reasonably expected with formal physical therapy as compared to an independent exercise program, which has been shown to be an appropriate intervention in the setting of chronic pain related to fibromyalgia and other generalized musculoskeletal pain conditions. In addition, there is a paucity of current data demonstrating the long-term safety and efficacy of traction in the setting of neck pain, cervical radiculitis, and cervical radiculopathy. Traction has not been shown to be an effective adjunct or substitute for standard conservative care including exercise, stretching, topical thermal modalities, and analgesics. For these reasons, the requested physical therapy for the neck including traction, physical therapy for the right hip including traction, and physical therapy for the right shoulder are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld

A 54-year-old female enrollee requested authorization and coverage of a Glucowatch. The Health Plan denied the request indicating that the requested equipment is considered investigational for treatment of the enrollees diabetes mellitus type I. Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested equipment is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested equipment is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested Nutropin AQ Nuspin 20 injector for the treatment of the enrollees medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The patient has a normal height, normal growth factors, and normal bone age.  Thus, he does not meet criteria for growth hormone deficiency.  There is no information on height and weight velocity over time.  Although the patient had low growth hormone levels in response to provocative growth hormone testing, the provocative testing was performed with inadequate sampling.  Typically, response to growth hormone is assayed over two to three hours on multiple samples after administration of each provocative agent.  All told, Nutropin AQ Nuspin 20 injector is not medically necessary for the treatment of this patient.   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 pediatrics with sub-specialty certification in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 6-year-old female enrollee has requested 30 hours per week of applied behavior analysis (ABA) therapy for 12 months for treatment of the enrollees autism and global developmental delay. Findings:  The physician reviewer found that ABA therapy has been in existence for at least 30 years and has been widely used in the therapeutic intervention in autistic children. In clinical trials, Dawson and colleagues conducted the first randomized, controlled trial to demonstrate the efficacy of a comprehensive developmental behavioral intervention for toddlers with ASD for improving cognitive and adaptive behavior and reducing severity of the ASD diagnosis. Further, when comparing patients treated with ABA therapy versus those who received standardized therapy, ABA is noted to provide a statistical improvement in cognitive, language, and adaptive behavior skills. Eikeseth stated that children who received ABA therapy made significant gains compared to those in special education. On average, the children who received the behavioral treatment gained 17 IQ points, 13 points in language comprehension, 23 points in expressive language, and 11 points in adaptive behaviors. In comparison, the eclectic treatment group obtained an average of +4 points in IQ, without further gains. On review of the new information provided in this patients case, she has not received three years of therapy as previously indicated by the Health Plan. In fact, she has only been participating in 30 hours per week of ABA therapy since said date. As reported by Lovaas in the peer reviewed medical literature, the requested 30 hours per week of intensive ABA therapy is required for at least one year in order for the patient to yield the maximum benefits from treatment. Thus, based on a recent progress report, the ABA therapy should be approved for this patient as medically necessary from the date requested and forward.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The patient was not experiencing post-acute withdrawal symptoms. He was not a danger to himself or others, and he was not aggressive or hostile. He was medically and psychiatrically stable. No medication changes had occurred. There were no emotional, behavioral, cognitive, or impulsive symptoms that would have warranted this level of care. He was motivated and working the program. Although he continued to struggle with his emotions, he could have continued treatment at an ambulatory level of care, where he could have continued to further develop insight and solidify coping skills, as well as take advantage of community-based 12-step programs. His family was supportive and involved in his recovery. Given his extensive substance abuse history with multiple prior residential treatments, the patient was well aware of, by his own admission, his propensity towards relapse. However, this is an inherent risk in the substance abuse population and in and of itself is not a reason to keep a patient in this level of care.  During the timeframe in dispute, he no longer met criteria for residential level of care.  All told, residential treatment center services 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 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.