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

A 39-year-old male enrollee requested authorization and coverage of at least 30 days of residential chemical dependency treatment services. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees alcoholism.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old female enrollee has requested X-Stop implantation surgery for treatment of spinal stenosis. Findings:  Two physician reviewers found that at this time, there is insufficient data to support the contention that X-Stop implantation is a superior treatment option. Simple laminectomy is the gold standard procedure for patients such as this patient. No study has demonstrated that X-Stop is more or as effective as laminectomy, particularly with a two-level procedure.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an inpatient stay for treatment of her medical condition.  Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for inpatient stay has not been established. In this case, the patients symptoms had resolved prior to admission, the vital signs were stable at the time of admission and the physical examination did not show signs of congestive heart failure or arrhythmia. In addition, the physician documentation did not include any reasoning for assignment of the inpatient status. All of the ordered services such as telemetry monitoring, repeat EKGs and diagnostic testing were of the intensity that could have been safely provided at the observation level. Had any complication or problem occurred, or the subsequent testing indicated myocardial ischemia, the patient could have appropriately been converted to inpatient status at that time. For the reasons provided, the services at issue were not medically necessary. 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 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 parent of an enrollee has requested inpatient hospitalization level of care for treatment of the enrollees behavioral health conditions.   The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient denied suicidal ideation. Additionally, it appears that the suicidal ideation expressed on admission and during her stay was passive in nature.  She had no plan or intent.  Her depression and related suicidal ideation were at least partially related to her chronic pain.  She was not homicidal, and she was not psychotic.  The patient was not cognitively or functionally impaired.  She was cooperative and engaged in treatment.  Her mood and coping skills had improved, and she was tolerating her medications.  She had improved and the records do not indicate that she would decompensate at a lower level of care.  Thus, the patient did not require 24-hour nursing supervision on an inpatient unit and could have safely been treated at a lower level of care.  All told, inpatient hospitalization was 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested testing for evaluation of the enrollees behavioral health condition.  Findings: The physician reviewer found that the testing was not medically necessary for evaluation of the patients medical condition. In general, the practice of pharmacogenetics, or the tailoring of a medication regimen based on an individuals genetic organization, may become a valuable tool in the treatment armamentarium for those plagued with psychiatric illness.  However, despite its promise, pharmacogenetics is not yet ready for mainstream clinical application. The American Psychiatric Association (APA) practice guidelines do not recommend genetic testing for cases involving routine medication management. Additionally, Severino and colleagues state that The search for molecular predictors of treatment response in [bipolar disorder] has so far produced limited evidence towards the involvement of specific genes in predicting response to treatments. While these findings are promising, they cannot constitute reliable markers with acceptable sensitivity and specificity that could be implemented in clinical settings. In this case, aripiprazole is a second-generation antipsychotic recommended for manic, hypomanic or mixed episodes. The data supporting aripiprazole for bipolar maintenance and bipolar depression are less robust. Considering the sub-therapeutic dosing of 5 and 10 mg daily and the patients history of nonadherence, the aripiprazole trial was inadequate by the date of the testing. The lamotrigine was adequately dosed but the medication is commonly titrated up to 400 mg daily for bipolar illness. Moreover, the patient had not yet exhausted standard mood stabilizing medications like lithium, lurasidone and olanzapine, while the dosing, duration and outcome of the quetiapine, and to a lesser extent the risperidone, were not presented. Additionally, outcome of evidence-based psychotherapies, such as cognitive behavioral therapy, interpersonal and social rhythm therapy and family therapy, or social-cultural-spiritual community activities, were not documented. Considering the relevant peer-reviewed literature and current practice standards, the disputed testing would not have been expected to yield information that significantly influenced treatment decisions, improved the patients condition, or prevented a more serious episode of illness. Accordingly, the testing at issue was not medically necessary for evaluation of the patients behavioral health condition.Final Result: The reviewer determined that the testing at issue was 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 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 58-year-old male enrollee has requested proton beam radiation therapy for the treatment of his prostate cancer. Findings:  The physician reviewer found that the definitive treatment of prostate cancer is either a radical prostatectomy or radiation therapy. Radiation can be delivered as either external beam or in the form of brachytherapy, which is a seed implant. Another form of radiation therapy is proton beam therapy which utilizes protons not photons. While proton beam therapy is a safe and effective treatment modality for prostate cancer, the evidence does not demonstrate that it is any more beneficial than intensity modulated radiation therapy (IMRT), which is standard radiation therapy. The clinical literature does not suggest that proton beam is superior to IMRT in terms of long-term outcome or side effects. One of the difficulties in evaluating proton beam therapy is the limited number of providers who offer the treatment and most of the scientific data are collected in retrospective studies. Based on the evidence available to date, proton beam therapy is not medically necessary for this patient as there are other therapies available in this setting that are equally effective.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Nicotinamide adenine dinucleotide (NAD) intravenous (IV) therapy. Researchers noted that fluoroquinolones are generally safe and well tolerated; however, rare but serious adverse events have been reported. The authors discussed the problem of persistent multisystem adverse effects as a possible complication. However, the authors did not provide any recommendations for treatment of quinolone toxicity. NAD IV therapy is not an effective treatment for quinolone toxicity. In this case, the records do not support the proposed diagnosis of quinolone toxicity as the underlying etiology of the patients multi-organ symptoms. The patients symptoms include a blotchy rash, intermittent left arm numbness and poor circulation in the left upper extremity. The records do not include a thorough work-up including physical examination and laboratory testing to assess for other potential causes for the patients symptoms. The current data does not support a role for NAD IV therapy in this clinical setting. Therefore, the requested NAD IV therapy is not 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 medication is 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 and 3 are board certified in family practice 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: Overturned

A 49-year-old female enrollee has requested Lap-Band evaluation and procedure for the treatment of her morbid obesity. Findings:  The physician reviewer found that a Lap-Band procedure is indicated to facilitate weight loss for this patient. This will allow the patient to reach a weight such that orthopedic intervention will be successful and she will be able to resume an exercise program. The patient has tried supervised weight loss programs without effect. The Lap-Band procedure is the least invasive mechanism for weight loss and is medically indicated for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 13-year-old female enrollee has requested growth hormone therapy (Genotropin) treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that although this patient has extreme short stature with an adult height prediction that is more than 2.5 standard deviations below normal for age and gender and a delayed bone age, the medical records submitted do not provide growth charts; longitudinal assessments of both weight and height velocity over time or a complete workup documenting that all other causes of short stature and/or poor growth and delayed puberty have been ruled out. Such causes include celiac sprue, underlying inflammatory conditions, eating disorders, and underlying systemic disease. If such documentation were provided, the patient might be considered an appropriate candidate for GH therapy for a diagnosis of idiopathic short stature. However, in the absence of such documentation, the medical necessity of growth hormone therapy is not established.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old female enrollee has requested for OxyContin CR/SR 80mg, 270 per month for treatment of her peripheral neuropathy. Findings:  The physician reviewer found that the peer-reviewed studies support the use of opiates in non-cancer pain as long as the total dosage is below the equivalent of 1 gram of morphine per day. The requested amount of OxyContin is less than the 1 gram per day equivalent. Ballantyne and Mao report that opioids were shown to be effective in the treatment of neuropathic pain, provided an adequate dose can be reached that provides analgesia without side effects.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Rituxan infusions for treatment of the enrollees myasthenia gravis. Findings: Two reviewers found that in the peer-reviewed medical literature, Iorio and colleagues noted that myasthenia gravis is an autoimmune disorder of the neuromuscular junction caused by circulating antibodies specific for the post-synaptic acetylcholine receptor or, in a minority of cases, for the muscle-specific tyrosine-kinase and the low-density lipoprotein receptor-related protein 4. A wide range of symptomatic and immunosuppressive treatments is currently available for myasthenia gravis patients with variable outcome. However, most immunosuppressive treatments are characterized by delayed onset of action and in some cases are not sufficient to induce stable remission of the disease. Lebrun and colleagues noted that Rituxan has demonstrated efficacy in limiting relapses in myasthenia gravis. Rituxan is a chimeric monoclonal antibody specific for the CD20 B-cell surface antigen. Recent studies have provided evidence that Rituxan may be an effective treatment for patients with myasthenia gravis who are refractory to standardized immunosuppressive therapy. Blum and colleagues reported that Rituxan at a dose of 1 g appears to be beneficial in the treatment of patients with severe myasthenia gravis. The records demonstrate that this patient has myasthenia gravis and has failed multiple therapies. Since the current medical literature supports the use of Rituxan in cases of myasthenia gravis refractory to other first-line therapies, the requested Rituxan infusions are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in neurology 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: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Synvisc One injections for treatment of the enrollees knee pain. The physician reviewer found that there is adequate medical evidence that intraarticular hyaluronic acid injections reduce pain and increase function in patients with knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Evidence from studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months (12 months after the last injection cycle), a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around two years. In addition, Campbell and colleagues conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis and found that intraarticular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. The patient is unable to tolerate NSAIDs, but has benefitted with intraarticular injections of hyaluronic acid in the past. Given this support, the requested Synvisc One injections are medically necessary for treatment of this patients bilateral knee osteoarthritis.  Final Result: The reviewer determined that the requested medication is service medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage Aptiom and Banzel.Banzel and Aptiom are both approved by the U.S. Food and Drug Administration for the management of epilepsy. It is estimated that 20 to 40 percent of seizure patients have drug-resistant epilepsy. Trials of additional anti-seizure medications can be of benefit in individuals with drug-resistant epilepsy. According to Gilioli and colleagues, sequential drug trials can produce remission rates estimated at four to six percent per year, or a cumulative rate of 14 to 20 percent. According to Neligan and colleagues, 29 percent of patients with drug-resistant epilepsy in which drug changes were made had 50 to 99 percent improvement in seizure frequency. In this case, the patient has tried and failed multiple anti-epileptic medications. Additionally, the patient has kept his seizures under control with Banzel and Aptiom. Thus, Banzel and Aptiom are medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested medications 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 neurology 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 62-year-old male enrollee has requested coverage for bilateral sacroiliac joint injections for treatment of his low back pain. Findings:  The physician reviewer found that the patient has a history of posterior lumbar spine fusion at L4-S1.  The joints below a fusion may become degenerated and serve as a major pain generator for some patients. Conservative therapy has failed to relieve the patients pain.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a dermatology consultation for evaluation of the enrollees rosacea. Findings:  The physician reviewer found that there is sufficient support for the requested services in this patients case. This patient does not qualify for referral because the primary care physician did not prescribe oral antibiotics. However, dermatologists generally prescribe the tetracycline family of antibiotics for the treatment of rosacea.  The request for coverage of a dermatology referral should be approved, as dermatologists are the physicians who specialize in the care of acne and rosacea.  The medical evidence supports the requested services in this clinical setting. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cardiac rehabilitation for treatment of myocardial infarction. Findings:  The physician reviewer found that based on the records provided the patient had a myocardial infarction less than one year ago, atypical chest symptoms, and adverse emotional consequences. In this circumstance, criteria for cardiac rehabilitation are met since the patient had a myocardial infarction less than one year ago. Monitored cardiac rehabilitation has the potential benefits of assessing for exercise induced dysrhythmias, recurrent exercise induced ischemia, improving functional capacity, developing confidence with activity, and improving psychological status through education typically provided at a cardiac rehabilitation program. Current guidelines also support the benefits of cardiac rehabilitation in patients after myocardial infarction. 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 internal medicine with sub-specialty certification in cardiovascular disease 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.