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

A 56-year-old female enrollee has requested inpatient residential treatment for treatment of her opiate and alcohol dependence.  Findings:  The physician reviewer found that the patient was placed on detox protocol for opioids on the said date, and significant lethargy during detox was noted.    During the time period, progress notes indicated that the patient was pleasant and sociable, with no somatic complaints.  Notes dated soon after indicated no cravings.  A week later, the medical notes indicated no cravings and no withdrawal. At this time the patient was cheerful, with full participation in the program.  She was taking Tylenol or ibuprofen for occasional back and neck pain. She was seeing a chiropractor. A week later, there were no cravings and no withdrawal. The patient remained cooperative and motivated during her stay, per the discharge summary. In this patients case, monitoring in a 24-hour setting was medically indicated from during the time period, given the patients chronic pain and medication adjustment.  Following detox, transitioning to a lower level of intensive outpatient care at the time would have been consistent with American Psychiatric Association treatment guidelines.  The patient was cooperative, with no medical complications or severe psychiatric comorbidity.  All told, inpatient residential treatment from the dates in question was medically indicated, and inpatient residential treatment was not medically indicated during the second time period at issue. I have determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha 140 mg/mL SureClick injectable medication for treatment of the enrollees arteriosclerotic cardiovascular disease (ASCVD).Findings:  The physician reviewer found that The records indicate that this patient has been able to take Lipitor 10 mg daily while other statins have not been tolerated. The patients LDL cholesterol is less than 100 but not less than 70, which is desirable in patients with established coronary artery disease. However, the American College of Cardiology (ACC) guidelines recommend a retreat from specific goals with more emphasis placed on taking moderate or high intensity statin. There are advocates for both approaches but there has been less emphasis on achieving an exact LDL cholesterol level. Repatha is generally reserved for patients with much higher LDL cholesterol levels than this patients LDL cholesterol of 100. Moreover, there is no documentation of this patients baseline LDL cholesterol prior to treatment. Considering all of these factors, the requested Repatha 140 mg/mL SureClick injectable medication 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 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.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 33-year-old female who has a long history of back pain. The patient also began experiencing neck and shoulder pain in January 2004. The patient indicates she has benefited from facet nerve block injections. The patients provider has recommended the patient receive additional facet nerve block injections for pain relief. The Health Plan has denied the request on the basis the requested injections are not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. Chronic facet nerve blocks are not the community or national standard of care for treatment of patients such as this patient. There are other more appropriate treatment modalities for this patients condition including radiofrequency ablation. Continued facet nerve blocks are not likely to be effective and are not medically indicated. Therefore, I have determined that the requested injections are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old female enrollee has requested a ductogram, ductoscopy and excisional biopsy for the treatment of her condition. Findings:  The physician reviewer found that a ductoscopy in the management of ductal lesions has been shown to be a useful tool in the evaluation of patients with nipple discharge per the study by Kapenhas-Valdes and colleagues. In that article, the authors concluded that many deeper intraductal abnormalities could be missed by blind surgical excision.  Ductoscopy has a role in the evaluation of women with abnormal nipple discharge and abnormal radiologic findings suspicious for a ductal origin.  The services at issue were medically indicated and appropriate for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old male enrollee has requested Roux-en-Y gastric bypass for treatment of his morbid obesity. Findings:  The physician reviewer found that with a BMI of 47.5 and documented comorbidities, laparoscopic Roux-en-Y gastric bypass is medically indicated and necessary for this patient, as it is not likely that he will be able to lose weight and maintain the weight loss through non-surgical means. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old female enrollee requested inpatient hospitalization stay for treatment of her elevated blood pressure during pregnancy.  Findings:  The physician reviewer found that the inpatient hospitalization stay was not medically necessary for treatment of the patients medical condition.In this case, according to the medical records submitted for review, at the time of admission her blood pressure (BP) was 142/85. There is no evidence that the patient had consistent hypertension after the initial BP reading. In addition, the FHTs were normal. There is a lack of evidence demonstrating that the patient required hospitalization for stabilization of BP or for reasons of possible or impending fetal compromise. Moreover, the discharge summary indicates that the patients blood pressures and vital signs were normal throughout the hospitalization. The patient could have been observed in a triage setting prior to consideration of the inpatient hospitalization. Based on the medical literature cited above and the documentation submitted for review, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 64-year-old male with a six-month history of weight loss, abdominal cramps and nausea. Colonoscopy, EGD, CT scan of the abdomen and pelvis and ultrasound have all been performed and the results were unremarkable. The patients stool cultures are negative and other laboratory work was also unremarkable. The patient has been treated with various medications including Zelnorm, creon, Beano and senna.  It appears from the providers notes that a small bowel follow through (SBFT) study is planned.  The patient is now requesting authorization for a capsule endoscopy.  His request was denied by the Health Plan based upon a determination that the diagnostic procedure is not medically necessary. The medical record provided does not support the use of capsule endoscopy.  Numerous diagnostic studies have already been performed, and it is not clear what diagnosis is being entertained by the patients provider or why a capsule endoscopy is specifically required. The patients request may require reconsideration pending the results of the SBFT.  Based upon the information set forth above, I have determined the requested procedure is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a 39-year-old male requesting reimbursement and prospective authorization and coverage for the residential treatment center (RTC) level of care.  Findings:  The physician reviewer found that The American Psychiatric Association treatment guidelines for substance use disorders recommend that residential treatment services or similar care higher than outpatient services are indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use, lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting.Patients require safe and stable living environments in order to develop their recovery skills thus qualifying for ASAM Level III treatment at least, similar to what this patient received at the facility.Although the patient makes statements at times minimizing his condition, his doctors feel strongly that he remains at high risk for relapse and self-harm. Given the severity of the patients illness, the RTC services were and are in accordance with generally accepted standards of medical practice and clinically appropriate for the patient's behavioral health condition. Therefore, the RTC services were and are medically necessary, and the Health Plans denial should be overturned.Final Result: The reviewer determined that the requested services were and 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: Medical Necessity
Decision: Upheld

A 25-old female enrollee has requested authorization and coverage for laparoscopic sleeve gastrectomy with cholecystectomy for treatment of the enrollees abdominal pain, cholelithiasis, and obesity.  Findings:  The physician reviewer found that although this patient is morbidly obese with a BMI greater than 40, the medical necessity of the requested laparoscopic sleeve gastrectomy with cholecystectomy has not been established at this time. The National Institutes of Health (NIH) consensus guidelines do not recommend bariatric surgery without documentation of prior failed weight loss efforts and compliance with nutritional regimens. In addition, a cholecystectomy would be considered medically necessary for symptomatic cholelithiasis, but this is not documented in the records. The patient should first be treated with dietary control. If the patient were to fail conservative treatment or develop acute cholecystitis, then surgical intervention could be considered. All told, the requested bariatric surgery has not been demonstrated to be medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 28-year-old female enrollee requested authorization and coverage of vein stripping. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees varicose veins.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar spinal fusion at L5-S1 for treatment of the enrollees L5-S1 annular tear with severe degenerative disc disease. Findings:  The physician reviewer found that as noted, lumbar fusion is a commonly performed procedure for the treatment of painful instability of the spine, usually manifest as chronic low back pain. This patients medical records show that the patient has degenerative back pain and disc degeneration. However, there is no evidence of lumbar instability, fracture, or tumor. Moreover, the patient has not reportedly failed conservative treatment. Thus, the established criteria for lumbar fusion have not been met. Accordingly, the requested lumbar spinal fusion at L5-S1 is not medically necessary for treatment of this patients back pain. Final Result: The reviewer determined that the requested surgery is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old male enrollee has requested a continuous passive motion (CPM) machine for treatment of his medical condition status post right knee arthroscopy and anterior cruciate ligament (ACL) reconstruction. Findings:  The physician reviewer found that although the use of a continuous passive motion (CPM) device after ACL reconstruction is common practice, there is a paucity of scientific evidence establishing its effectiveness (Rosen, et al). In one study from Richmond and colleagues, there was no significant difference observed between patients with short- or long-term use of CPM post-operatively. In addition, Witherow and colleagues reported comparable health outcomes in patients six months after surgery with or without use of a CPM device. Similarly, Wright and colleagues concluded that no clinical benefit was identified for CPM use following ACL reconstruction surgery. As such, it remains unsettled whether post-operative use of a CPM device offers any benefit and further study is needed. Therefore, the use of the CPM device in this patients care following ACL reconstruction has not been established as medically necessary and therefore the denial was appropriate.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested acupuncture for treatment of fibromyalgia.  Findings:  The physician reviewer found that there were no objective or subjective findings/factors discernible in the notes provided. The evidence submitted does not provide objective documentation that the patient has benefited from previous acupuncture treatments or is likely to benefit from additional acupuncture at this time.
Appeal type: Urgent Care
Decision: Overturned

The parent of a six-year-old female enrollee has requested  for emergency services  for treatment of the enrollees fever and vomiting.  Findings:  The physician reviewer found that the patients symptoms met prudent layperson criteria for emergency care. A prudent layperson parent with an average knowledge of medicine and a child with persistent vomiting and fever would reasonably expect the absence of emergency care to jeopardize the childs health. These symptoms are very concerning in a small child because dehydration can occur quickly. Vomiting and fever alone may signify acute gastroenteritis, food poisoning, urinary tract infection, or respiratory tract infection (sinusitis, pharyngitis, pneumonia), to name a few. The parent appropriately sought emergency medical care for the patient because of the persistence of her symptoms. Several days of fever and vomiting are enough to deplete a childs system of enough fluid to cause significant dehydration. In addition, these symptoms may suggest a serious condition such as pneumonia, pyelonephritis, or strep throat, all of which require antibiotic therapy. The presumed chest discomfort complicates the presentation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Percocet for treatment of the enrollees pain. Findings:  The physician reviewer found that The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. Absent a change in the fracture status or the development of complex regional pain syndrome, there is no indication for stronger opiates. The Centers for Disease Control and Prevention guidelines do not support ongoing opiates for chronic, non-malignant pain, such as in this case. The current medical evidence does not support the requested medication in this clinical setting. All told, Percocet 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested placement of a left ventricular pacing lead add-on for treatment of his medical condition.   Findings:  Three physician reviewers found that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of support for placement of a left ventricular pacing lead add-on in this clinical setting. The peer-reviewed literature does not support left ventricular pacing lead, unless the patient has left bundle branch block morphology and QRS duration more than 150 milliseconds. In this case, the patient has a QRS complex of less than 120 milliseconds. In addition, the patient does not have permanent atrial fibrillation or a near 100% ventricular pacing need. Therefore, the placement of the left ventricular pacing lead add-on is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the requested services are 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. All three 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Actiq, fentanyl citrate 1600 mcg.Findings:  The physician reviewer found that the medical records have shown the patient to have chronic non-malignant pain. There is convincing evidence that patient education, exercise therapy, and cognitive behavioral therapy are the cornerstones for the treatment of chronic pain. The current standard of care for chronic pain is treatment in a multidisciplinary practice that includes physical therapy, massage therapy, behavioral therapy, and steroid injections. Based on a study, there are Well-established guidelines, for routine back pain, stress conservative management, including use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen and physical therapy There are a variety of anti-convulsants and anti-depressants considered adjunctive to pain management therapy. If there is poor response to conservative therapy, then surgery should be considered. High dose opioids are associated with a high risk of dependence and tolerance and are therefore not recommended. The studies have shown that short-acting opiates are more   likely to cause adverse outcomes. In this patients case, he has been on Actiq: fentanyl citrate 1600 mcg for over seven years. The requested medication is excessive in light of the patients medical condition and in addition to his medication regimen. Final Result: The reviewer determined that 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 16 home health skilled nursing visits (twice a week for eight weeks). As noted in the medical literature, home health skilled nursing services can help prevent recurrent hospital admissions and frequent use of emergency services in patients who have multiple complications due to chronic illnesses. Skilled nursing services provided at a patients home are indicated when medication management, skin injury, wound care, and/or monitoring of nutrition status are included in the patients care plan. A registered nurse (RN) or a licensed practical nurse (LPN) can provide home health skilled nursing services. Home health nurses provide direct services and teach patients as well as caregivers about patient care. In addition, home health nurses manage, observe, and evaluate a patients care. In this case, the patient would benefit from the requested 16 home health skilled nursing visits to help manage his chronic conditions including diabetes, skin infection, edema, monitoring of blood pressure and mentation as well as medication management. In this clinical setting, the requested 16 home health skilled nursing visits (twice a week for eight weeks) are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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.