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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for percutaneous vertebral augmentation units: 1 Findings:  The physician reviewer found that  Health Quality Ontario reports that cancers that metastasize to the spine and primary cancers such as multiple myeloma can result in vertebral compression fractures or instability and that conservative strategies, including bed rest, bracing, and analgesic use, can be ineffective, resulting in continued pain and progressive functional disability limiting mobility and self-care. The authors note that both vertebroplasty and kyphoplasty significantly and rapidly reduced pain intensity in cancer patients with vertebral compression fractures, significantly decreased the need for opioid pain medication, and resulted in functional improvement areas involved. Srensen and colleagues report that percutaneous vertebroplasty and kyphoplasty are safe and effective palliative procedures for painful vertebral compression fractures due to malignancy. Given the current medical literature, the requested services are medically indicated. Therefore, percutaneous vertebral augmentation units: 1  is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service 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 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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for partial hospitalization program (PHP) level of care services She was admitted to a residential treatment center (RTC). She stepped down to a partial hospitalization program (PHP) from a residential treatment center. The enrollee began to binge as a way of coping. She used laxatives and diet pills as part of purging behavior. . She reports symptoms of anxiety with shortness of breath and tightening of the chest, and depressed mood, nightmares and feelings of hopelessness. Findings:Her diagnoses on admission were bulimia nervosa and adjustment disorder with mixed anxiety and depression. She stepped down to a PHP program. She reported moderate anxiety, depression and frustration. She denied suicidal ideation or homicidal ideation or psychotic symptoms. She met her treatment goals during her time at PHP and maintained a stable weight with a fluctuation of 1-2 pounds.  She was able to gain some coping skills to deal with distress and started attending meetings to address her difficulties with co-dependency in relationships. Her condition at discharge included frequent eating disorder symptoms, and obsessive thoughts related to her eating disorder behaviors 80% of the time. Utilizing LOCUS criteria, the enrollees risk of self-harm score is 1.  There was no indication of suicidal or homicidal thoughts or impulses, and no history of suicidal or homicidal ideation. She had the clear ability to care for herself now and in the past. Functional status score is 2. She was experiencing some deterioration in interpersonal interactions. However, she is demonstrating significant improvement in function following a period of deterioration. Medical, addictive and psychiatric co-morbidities score is 2. She may occasionally experience psychiatric symptoms, related to stress, and medical illness. Recovery environment  level of stress score is 3 due to significant discord or difficulties in family or other important relationships or alienation from social interaction. Recovery environment  level of support score is 2; professional supports are available and effectively engaged. Treatment and recovery history score is 2. Recovery has been managed for moderate periods of time with limited support or structure.  Engagement and recovery status score is 2. The enrollee has significant understanding and acceptance of illness. The enrollees composite score is 14 which correlates to low intensity community based services.  Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 64-year-old male enrollee has requested authorization and coverage for Orthovisc injections. Hyaluronic acid injection for osteoarthritic knee pain is generally considered a second-line treatment option after independent exercise, weight loss and medications such as non-steroidal anti-inflammatory medications and/or acetaminophen. The provider noted the patient presented with mild left knee pain. However, there is no documentation of left knee osteoarthritis and no mention of any prior treatment for symptoms attributed to left knee osteoarthritis. Given the lack of documentation supporting an indication for the requested hyaluronan injections, the requested Orthovisc injections are not medically necessary for treatment of this patients mild knee pain. 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intraoperative radiation therapy (IORT). This patient presents with estrogen receptor (ER) positive (99%), progesterone receptor (PR) positive (100%), human epidermal growth factor receptor 2 (HER2) negative, grade I invasive ductal carcinoma. Per the American Society for Radiation Oncology (ASTRO) guidelines, this patient meets the criteria for the suitable group for the use of IORT in patients with invasive ductal cancer (Correa, et al.). Phase 3 studies have shown equivalent outcomes in patients who undergo standard radiation therapy and IORT. Therefore, this patient meets the criteria for treatment with IORT. All told, the requested IORT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested IORT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation oncology and is 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 parent of an enrollee has requested authorization and coverage for Nutropin AQ 20 mg for treatment of the enrollees short stature. Findings:  The physician reviewer found that there is sufficient support for the requested medication in this clinical setting.  This patients pre-treatment height was more than two standard deviations delayed, and his bone age was delayed for chronological age.  According to the Pediatric Endocrinology Society guidelines, a trial of growth hormone therapy should be approved for children with otherwise unexplained short stature who pass growth hormone stimulation tests but who meet most of the following criteria: height more than 2.25 standard deviations below the mean for age or more than two standard deviations below the mid-parental height percentile; growth velocity less than the 25th percentile for bone age; bone age more than two standard deviations below the mean for age; low serum insulin-like growth factor 1 (IGF-1) and/or insulin-like growth factor-binding protein 3 (IGFBP-3); and/or other clinical features suggestive of growth hormone deficiency.  This patient does meet some of the above criteria, and his growth has accelerated while on growth hormone therapy.  Continuation of therapy is medically necessary for this patient.  All told, Nutropin AQ 20 mg is medically indicated 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 physician 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: Upheld

A 45-year-old male enrollee has requested for OxyContin 80mg for treatment of his chronic pain. Findings:  The physician reviewer found that the use of long-acting opiates is justified in chronic pain patients to improve their lifestyle, using convenient once or twice daily dosing. The half-life of Oxycontin is four to five hours, so every nine hours is a reasonable dosing interval for two half-lives. BID is the normal starting dose frequency. Depending on the chronicity of a patients pain, an increase in total dose to over 160 mg/day can be reasonable, but instead of QID dosing, an increase in dosage to 100-120 mg TID (three times a day) allows maintenance of the blood and plasma levels at the same steady state as an 80 mg QID dose. However, the accepted standard of care in this setting is to attempt other alternatives prior to pursuing a TID dose of Oxycontin. Alternative therapies in this setting include Synvisc injections, surgery and other medications such as Nucynta, Lyrica, Neurontin and non-steroidal anti-inflammatories. It is appropriate to attempt such therapies before narcotics are increased to higher dosages. This is because opioid-induced hyperalgesia is a possibility at a dose of Oxycontin above 80 mg BID. Another alternative is narcotics rotation (such as morphine, oxymorphone, Fentanyl, and Exalgo (hydromorphone) and is appropriately considered in patients who are very tolerant to their current medication.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 54-year-old female with a history of fibromyalgia and pain in her neck, right hip, feet, knees, hands and wrists.  She had land-based physical therapy in the past which did not help with symptom reduction. She also had cervical epidural steroid injections and subacromial injections with temporary relief of symptoms. Aquatic therapy was recommended by her provider in January 2005. The patient received aquatic physical therapy with therapeutic pool exercises in February 2005. A subsequent prescription for a pool exercises program dated July 2005 was also included in the record.  The patient has requested reimbursement for the aquatic therapy provided in February 2005 and prospective authorization for additional aquatic therapy.  The Health Plan has denied these requests based upon a determination that the therapy was/is not medically necessary.Although the patient has a chronic condition, she had not had much relief with traditional land-based physical therapy alone.  A trial of aquatic therapy was reasonable and consistent with Medicare guidelines and standards within the medical community. The aquatic therapy provided in February 2005 was medically necessary and should have also included a component of patient education.  Authorization for ongoing aquatic therapy is not medically necessary, as the patient should have been provided with the instruction necessary to continue her aquatic exercise program independently.Based upon the information set forth above, I have determined that although additional aquatic therapy is not medically necessary for treatment of the patients medical condition, the therapy provided in February 2005 was medically necessary for treatment of the patients medical condition. The Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee requested authorization and coverage for proton beam radiation therapy. The health plan has denied this request indicating the requested therapy is not medically necessary for treatment of the enrollees left frontal glioma. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old male enrollee requested authorization and coverage of one-on-one physical therapy sessions three times per week. The Health Plan denied the request indicating that the requested therapy is not medically necessary for the treatment of the enrollees bilateral knee pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Fasenra. The U.S. Food and Drug Administration (FDA) approves the use of Fasenra for the management of severe asthma in adults with an eosinophilic phenotype. The Global Initiative for Asthma (GINA) strategy for asthma management and prevention reports that benralizumab may be used to treat adult patients with severe eosinophilic asthma that is uncontrolled on standard therapies. In this case, the patient has an eosinophilic phenotype based on an elevated peripheral eosinophil count of 817. His asthma is inadequately controlled on standard therapy comprising of Breztri, a long-acting beta2-adrenergic agonist (LABA), dexamethasone, a synthetic adrenocortical steroid, and Jardiance. In this clinical setting, the requested medication is medically indicated for the management of the patients eosinophilic asthma. Therefore, Fasenra 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 internal medicine with sub-specialty certification in pulmonary 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: Overturned

A 41-year-old male enrollee has requested continuous passive motion (CPM) machine for treatment of his medical condition status post reconstruction of the left anterior and posterior cruciate ligaments and medial collateral ligament.  Findings:  The physician reviewer found that the records indicate that it was medically necessary for this patient to use the CPM device as recommended by his provider following his two-staged reconstruction of the knee. Although the use of CPM has not been supported after total knee replacement, this patient has a personal history of thrombophlebitis and required a two-stage procedure. In the article by Chen and colleagues, a prospective controlled study was conducted on 107 patients treated with basic rehabilitation protocols. The authors concluded that aggressive CPM does not provide obvious benefits. Trzeciak and colleagues evaluated 93 patients who were assigned to two groups. The authors stated the findings showed that CPM had no significant advantage in terms of improving clinical measurements. In the article published by Harvey and colleagues, the authors review of controlled trials revealed there is evidence that CPM increases passive knee flexion range of motion by a mean difference of 2 degrees and active flexion range of motion by a difference of 3 degrees. However, the authors concluded that the effects are too small to be clinically substantial. The presence of multiple ligament injuries and a past history of thrombophlebitis in this patient support the appropriateness of the use of a CPM in his post-operative rehabilitation. This case is unusual since the patient had a two-stage procedure and a full array of ligamentous injury, as well as past history of deep vein thrombophlebitis. Given the combination of ligament injuries, the use of a CPM device was appropriate.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old male enrollee has requested for inpatient psychiatric care for treatment of her behavioral health condition. Findings:  The physician reviewer found that clinical evidence demonstrates that the patient was only marginally stable after his first admission and needed re-admission in order to further stabilize his condition. Additionally, further treatment at an intensive level of care was needed to recruit the patients cooperation in his treatment plan.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 57-year-old female with bilateral meniscus tears. She has pain during work and exercise and would like to attempt physical therapy. The Health Plan has determined physical therapy will not benefit the patients condition and that the patient should proceed with surgery.The patient has had a physical therapy evaluation. The results of this evaluation indicate the patients range of motion is full and that her strength is 5/5. Therefore, there are no physical therapy goals for the patient to achieve. Furthermore, there is little, if any, evidence demonstrating physical therapy would improve the patients underlying condition of meniscus tears. There is no likelihood that physical therapy would assist in this patient avoiding surgery. Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient presents with a complaint of nasal congestion, which has been present for almost two years. The medical records indicate the patient was evaluated for this condition two years ago. A CT scan was performed and surgery was recommended. Because of the patients fear of surgery he deferred treatment, but now returns for care. The patient states that he has been using nasal sprays, which have been somewhat effective. However, the patient reports the nasal sprays have begun to lose their effectiveness. The medical records state the patient has been given numerous antibiotics for his condition, but they have failed to clear the problem. The physical exam documents a severely deviated septum and a hyponasal voice. A CT scan from August 2004 revealed extensive sinus disease, which had not improved from a prior study of May 2002. A chart note from June 2002 recommended nasal sprays, allergy screening, and four weeks of antibiotics with a repeat of the CT scan. The patient now wishes to proceed with nasal surgery. The Health Plan has denied the request on the basis that the requested surgery is not medically necessary for treatment of the patients medical condition.The patient has a nasal obstruction with both physical and CT evidence of a mechanical cause for this obstruction. Though he may have had some previous issues with compliance, the patient has made a reasonable effort with conservative management. The patient continues to be symptomatic. Though management of allergy and soft tissue swelling can reverse some cases of rhinosinusitis, the physical findings indicate the patient has a severely deviated septum with no improvement in his condition over the past two years. As such, the patients condition needs to be treated surgically. Therefore, I have determined the requested surgery is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested continued transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this patients case.  TMS therapy carries less risk when compared to electroconvulsive therapy.  Additionally, TMS therapy has been endorsed by the American Psychiatric Association in its current clinical practice guideline for the treatment of individuals with depression.  In this particular case, the patient received TMS during an acute depressive episode and achieved a significant clinical response, if not remission.  However, the utility of TMS in long-term and/or maintenance treatment for major depressive disorder has not been established by the scientific community.  Thus, there is a lack of support for TMS therapy from the said date forward in this clinical setting.  The application of TMS as maintenance, preventative or long-term therapy for major depressive disorder is not supported by the current medical evidence.  All told, TMS therapy during this time frame was not and is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee requested authorization and coverage of follow-up care with a cardiologist or electrophysiologist. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollee status post cardiac pacemaker dependence.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.