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

The patient has requested authorization and coverage for additional power features including tilt in space, recline, seat elevation, and power elevating leg rests for the approved Group 3 power wheelchair. A review of the literature supports the relationship between self-care and functionality of patients with multiple sclerosis as well as a multidisciplinary approach to managing and adapting to the needs of multiple sclerosis patients with disease progression. This patients DME evaluation indicates the appropriate power mobility device for this patient is a Group 3 power wheelchair with a single power option, such as tilt in space, and a pressure relief cushion. There is a lack of evidence in the documentation that the patients current medical needs and ADLs are unable to be completed without a seat elevation or power elevating leg rests. The patient does not have a history of extremity contracture or spasticity. The DME evaluation indicates that the patient requires minimum to moderate assistance for transfers without any seat elevation. In addition, the patient does not require a reclining feature to assist with bladder care or lower body dressing, as she is at minimum assistance for lower body dressing and toileting and has assistance 23 hours per day. Furthermore, the tilt in space option and pressure relief cushion on the approved Group 3 power wheelchair will address the patients medical needs as recommended in the DME evaluation. All told, the tilt in space power feature is medically necessary, while the remaining additional power features including recline, seat elevation, and power elevating leg rests for the approved Group 3 power wheelchair are not medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the requested equipment 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 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

A female enrollee requested magnetic resonance imaging (MRI) of the right knee for medical evaluation of her knee pain. Findings:  The physician reviewer found that the medical records submitted for review do not demonstrate any physical exam findings of joint looseness or tendon impingement. In addition, there is no documentation of a course of physical therapy that has been tried and failed. The medical records also do not indicate a trial of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen for three or more weeks, which is an accepted standard of care treatment prior to an MRI study being performed. Based on the clinical documentation submitted for review, the medical necessity for the MRI of the right knee has not been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acupuncture visits, once a week, for six to eight weeks. The available records support a diagnosis of left shoulder pain. The patient has requested treatment with acupuncture. Vickers and colleagues noted that, Acupuncture is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain. The authors concluded that, Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain. As this patient has continued to be symptomatic, an acupuncture trial for pain management and function improvement was indicated and supported by the peer-reviewed medical literature. Eleven acupuncture sessions were completed. According to the patient, the acupuncture completed was beneficial. Despite such statement, no pre-acupuncture, and post-acupuncture baselines (activities of daily living-range of motion-medication intake-function) were documented by the patient, the acupuncturist, or the medical practitioner for comparison purposes. After prior acupuncture (11 sessions) was completed, the records reviewed failed to document any measurable, progressive, significant, objective functional improvement (quantifiable response to treatment) obtained with previous acupuncture to support the necessity of the additional acupuncture. As no current physical examination was documented, the clinical findings, including the deficits (motor-sensory-functional) to be addressed by the additional acupuncture treatments, are unknown. Therefore, the goals to be obtained with the additional acupuncture are unclear. Additionally, there is no clear documentation indicating whether the patient is consistently undergoing an independent exercise program (conditioning-aerobic-stretching exercise program based on the patients tolerance) concurrent with the acupuncture care, which is supported by the peer-reviewed literature to avoid deconditioning and dependency on passive care. Given these findings, the requested acupuncture visits, once a week, for six to eight weeks are not medically necessary for 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 a licensed L.Ac., board certified in oriental medicine and acupuncture, 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 35-year-old female enrollee has requested Tarceva 150mg for the treatment of her metastatic lung cancer. Findings:  The physician reviewer found that Tarceva is approved for use in non-small cell carcinoma of the lung after failure of first-line chemotherapy. However, there appears to be certain situations wherein there is a particularly good chance of a response without the side effects of chemotherapy. The most prominent of such is in a patient such as this one. Thus, Tarceva would be considered a very reasonable and medically necessary treatment choice in this palliative situation. This would represent a fairly common decision amongst oncologists. Furthermore, there has been very poor correlation between an EGFR mutation and response to Tarceva, such that oncologists do not view this as a necessary test to perform prior to the institution of Tarceva.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested authorization and coverage of a referral to an orthopedist. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees back pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested services are medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 54-year-old male with hypersomnia as indicated by his letter and documented by his neurologist. He reports excessive sleepiness and fatigue, which is apparently not due to medication side effects. Diagnoses of migraines and anxiety have also been made. His neurological exam was not notably abnormal. The patient was treated with a variety of medications before his neurologist initiated Provigil for his symptoms. Valium had been used at times for anxiety, but the hypersomnia persisted even when the patient did not take Valium. A previous trial of Ritalin was reportedly associated with severe side effects, although the details were not reported.  When Provigil was first prescribed there were initial side effects that are now resolved. The patient is reportedly much improved, both in regard to his sleepiness and his migraines. There was no indication in the record that a sleep study had been done.  The patient has requested reimbursement and continued authorization for Provigil. The Health Plan denied the request based on a determination that the medication was/is not medically necessary for the treatment of the patients hypersomnia.The patients diagnoses include migraine headaches, anxiety, and excessive daytime sleepiness. Although the etiology of his hypersomnolence has not been identified at present, his provider noted definite improvement with Provigil after the failure of several other medications.  Provigil is clearly effective in treating the patients hypersomnolence and has resolved his migraine headaches as well without continuing side effects. I recommend that it be continued, and that in addition, he undergo nocturnal polysomnography to evaluate for possible sleep apnea that may present with both excessive sleepiness, and headaches. Based upon the information set forth above, I have determined the medication at issue was/is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Otezla. Kaushik and Lebwohl note that treatment regimens for psoriasis patients should be tailored to meet the specific needs based on disease severity, the impact on quality of life, the response to previous therapies, and the presence of comorbidities. Zakhem and colleagues note that systemic dermatologic medications may have effects on male fertility. In this case, the documentation reflects that the patient has psoriasis affecting about 11% of his BSA that has not improved with topical steroids. Given the patients history of hypercholesterolemia and as he is considering pregnancy with his wife, the provider has recommended Otezla. In this clinical setting, the requested medication is medically indicated. Therefore, Otezla is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is 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 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: Upheld

The parent of a 20-month-old female enrollee has requested direct one-on-one applied behavioral analysis (ABA), speech therapy and occupational therapy for treatment of the enrollees medical condition. Findings:  The physician reviewer found that based on the documentation submitted, the patient has borderline to mild developmental delay, a significant expressive language delay for age and she is at risk for autism. The gold standard for the diagnosis of toddler autism is the Autism Diagnostic Observation Scale and when tested the patient was reported to be at a moderate to severe concern for autism. However, none of the subsequent studies confirm a diagnosis of autism. According to Zwaigenbaum and colleagues, screening for autism is possible between 18 to 24 months; however, there are marked difficulties in establishing a clear-cut diagnosis and significant challenges in therapy. Martinez-Pedraza and Carter also emphasize the difficulty in establishing a diagnosis of autism below the age of 2. Given that the patient is not clearly identified as autistic, an extensive program of ABA therapy is not supported at this time. Based upon the submitted clinical documentation, the patient does not currently present with deficits that require both occupational and speech therapy. As such, the requested frequency of occupational and speech therapy is not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 64-year-old woman with a left sciatic nerve injury, which is likely related to a left hip surgery. This is a well-documented complication. The patient has experienced persistent weakness for 1.5 years associated with chronic pain. The submitted information indicates the patient has been seen by two neurologists, an orthopedist, and two pain management specialists. The patient has requested authorization for a consultation at a specialized sciatica clinic. The Health Plan indicates the requested consultation is not medically necessary for diagnosis and treatment of the patients medical condition.The patient has a traumatic sciatic neuropathy, which has shown no evidence of recovery. Unfortunately, the patients condition does not lend itself to definitive therapy. The submitted information does not provide any medical justification for the requested consultation. There is no evidence that the patient cannot receive appropriate care within network. Furthermore, there is no indication that the requested clinic offers services that would necessitate a referral to that institution. Thus, the requested consultation is not medically indicated. The patient may benefit from a neurosurgical consultation to determine if nerve exploration and neurolysis may be appropriate.Based upon the information set forth above, I have determined that the requested consultation is 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 49-year-old male enrollee has requested right knee meniscal allograft replacement, medial major debridement, chondroplasty and anterior cruciate ligament reconstruction surgery for treatment of his right knee instability secondary to chronic anterior cruciate ligament insufficiency.  Findings:  The physician reviewer found that the current status of the use of paste graft is not supported in the clinical literature as having equal or better outcomes than standard alternative procedures. The primary support for paste graft procedures is based on small case reports or anecdotal reports of benefit. There is insufficient scientific literature to allow for a meta-analysis comparing the proposed surgery to other procedures. All told, there is not enough reliable data to establish the role of a surgical procedure utilizing paste graft procedures and meniscal allograft replacement in this setting.
Appeal type: Medical Necessity
Decision: Overturned

A 36-year-old male enrollee requested authorization and coverage of facial collagen injections for the treatment of lipoatrophy.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 107 hours per month of applied behavioral analysis (ABA) therapy (86 hours per month of direct therapy, 17 hours per month of supervision and four hours per month of parent training) for treatment of the autism. Findings:  The physician reviewer found that the request for ABA therapy at the frequency of 107 hours per month (86 hours per month of direct therapy, 17 hours per month of supervision and four hours per month of parent training) has been established as medically necessary for treatment of the patients autism. One study found that ABA was effective to decrease disruptive behaviors in school age children with autism. In this case, the patient requires a higher level of ABA services due to his maladaptive behaviors that include tantrum, elopement and self-biting. Therefore, based on the records submitted for review the requested services are medically necessary for treatment of the patients autism. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 reimbursement and prospective authorization and coverage for osteopathic manipulation services. A study of the immediate effects of osteopathic treatment compared with therapeutic exercise showed that both interventions were associated with immediately improved range of motion (ROM) and pain after treatment. The American Osteopathic Association guidelines for osteopathic manipulative treatment do not show high quality supporting manipulation over other care techniques for chronic low back pain. Overall, there is a lack of evidence to support that long-term osteopathic manipulation is more beneficial for chronic neck and low back pain than any standard therapy. Thus, the osteopathic manipulation services provided were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the osteopathic manipulation services provided were not and are 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 osteopathic manipulation services provided were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in physical medicine and rehabilitation 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: This is a patient with chronic right hip pain. She has been diagnosed with osteoarthritis. She was scheduled for right total hip arthroplasty with discharge to home following inpatient admission. Physical examination of the right hip revealed painful flexion and extension and the inability to do internal and external rotation. Recommendations regarding post-operative care included ice, heat, modified, walking and follow-up as needed. The patient requested a referral to a skilled nursing facility (SNF) for postoperative care. She reported that she lives on her own and does not have anyone to care for her following surgery.The records provided for review noted the patient had made a reasonable attempt to find at-home assistance. SNF admission following joint replacement surgery is generally supported by evidence-based medical literature. In this case, the patient is of advanced age, lives alone and had inadequate post-operative in-home support services, and presents as an increased fall risk. Therefore, the requested SNF services after hip replacement surgery are medically necessary for the treatment of this patients medical condition.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: Medical Necessity
Decision: Overturned

The patient has requested reimbursement and prospective authorization and coverage for oxymorphone immediate-release (IR) 10 mg every eight hours as needed for breakthrough pain (60 tablets/20 day supply) and oxymorphone extended-release (ER) 15 mg twice a day for chronic pain. The Federation of State Medical Boards guidelines state, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. The Centers for Disease Control and Prevention (CDC) guidelines noted that, non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. In this case, the patient has experienced intractable debilitating migraines for several years. The providers note outlines the numerous prophylactic and abortive medications that were ineffective to manage the patients condition. The patients treatment plan includes non-opioid- based therapy. The letter from the provider reports that the patient has shown functional benefit with oxymorphone. The patients CURES report and urine drug screens have been consistent with his treatment regimen and the patient has not demonstrated aberrant drug behavior. Furthermore, the patients treatment plan is to wean the patients opioids over the next six months. Given these findings, oxymorphone IR 10 mg every eight hours as needed for breakthrough pain (60 tablets/20 day supply) and oxymorphone ER 15 mg twice a day for chronic pain were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the medications at issue 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 anesthesiology with subspecialty certification in pain management 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.