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

The patient is a female diagnosed with asthma, type 2 diabetes, fibromyalgia, hallux valgus with bunions, and chronic low back pain with bilateral sciatica. The patient reported that she was unable to walk to a bus stop and was unable to sit on a bus for prolonged periods of time due to back pain. The patient underwent a functional mobility assessment. The patient was able to ambulate in her home without the use of a walker. She has a history of using a four-wheeled walker with a seat for ambulating longer distances in the community. The patients home was not wheelchair accessible. The patients upper and lower extremity strength was noted to be within functional limits. Her sitting and standing balance was intact. There was no history of falls. The patient has requested coverage for a power operated vehicle (motorized scooter). The Health Plan denied the request and reported the requested equipment is not medically necessary for the treatment of this patient. At issue in this case is whether a power operated vehicle (motorized scooter) is medically necessary for treatment of the patients medical condition. In this case, the record does not document functional mobility limitations that impair the patients ability to participate in her activities of daily living (ADL), and there is no mobility limitation that is not correctable by cane or walker. The patient can ambulate in her home with or without a walker and historically has used a four-wheeled walker for ambulating longer distances in the community.  There is no described absence of upper extremity function preventing the self-propelling of a manual wheelchair to perform her ADLs. The medical evidence does not support the requested equipment in this clinical setting. Therefore, the requested power operated vehicle (motorized scooter) is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a six-year-old male enrollee has requested an occupational therapy evaluation for treatment of the enrollees sensory regulation and fine motor difficulties. Findings:  The physician reviewer found that the submitted clinical records provide no medical basis for the patients eye-hand coordination, fine motor function, paragraph summarization and short-term/sequential memory difficulties. Since these issues are only documented as issues with school, they are considered educationally necessary and should be addressed through an Individual Education Plan (IEP). The patient is age appropriate for activities of daily living and self-help skills.
Appeal type: Experimental/Investigational
Decision: Upheld

A 27-year-old female enrollee has requested Neurostar Transcranial Magnetic Stimulation (TMS) therapy for the treatment of her major depression. Findings:  Three physician reviewers found that TMS is not a first-line treatment for depression. There is inadequate data to support its efficacy over standard treatment. Brunelin and colleagues stated that, For patients with treatment resistant depression, TMS appears to provide significant benefits in short-term treatment studies. However, the relatively low response and remission rates, the short durations of treatment, and the relative lack of systematic follow-up studies suggest that further studies are needed before TMS can be considered as a first-line monotherapy treatment for treatment resistant depression. Treatment failures must be substantiated before pursuing TMS therapy. The classification of treatment resistant depression should be established by clinical assessment, psychometrics and treatment failures. It must first be evident that treatment failed to achieve improvement or remission despite adequate trials with a variety of antidepressants, alone or in combination with psychotherapy. In addition, it should be demonstrated that these trials failed when coupled with standard augmentation agents. Based on the information provided, these criteria were not met by this patient prior to pursuing TMS therapy.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a six-year-old male enrollee has requested  growth hormone (GH) Genotropin for treatment of the enrollees short stature.  Findings:  The physician reviewer found that this patient has short stature but normal height velocity, normal growth factors, normal bone age, and a normal response to provocative GH testing. Thus, he does not have classic GH deficiency. His bone age is too young to make a formal prediction of final adult height. According to the Lawson Wilkins Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than two standard deviations below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than two standard deviations below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. Based on the information provided, this patient does not meet most of these criteria. All told, the requested GH therapy with Genotropin is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi and ribavirin for 24 weeks for treatment of her hepatitis C.  Findings:  Two physician reviewers found that the proposed treatment regimen is considered the standard of care in this clinical setting.  The requested medications are likely to prevent further disease progression.  The current medical evidence support combination therapy with Sovaldi and ribavirin for patients with hepatitis C, genotype 3 infection.  Per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, the medical evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  All told, Sovaldi and ribavirin for 24 weeks is medically indicated for the treatment of this patient. Final Result: Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Overturned

The patient has been diagnosed with bilateral knee osteoarthritis, and is requesting Synvisc One injection in the right knee.  Findings: Medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patients options are limited. The patient has tried and failed other conservative treatments, including a corticosteroid injection and physical therapy, with the alternative being a total knee arthroplasty. The medical evidence supports the requested service in this clinical setting. Therefore, a Synvisc One injection in the right knee 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: Overturned

A 52-year-old female enrollee requested authorization and coverage for the medication Lamisil. The health plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees onychomycosis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the health plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A male enrollee has requested reimbursement for hospitalization services provided at Rancho Los Amigos National Rehabilitation Center. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees pressure ulcer. Findings: In this case, the patient had complex wound care needs. He had already undergone a girdlestone hip procedure and developed a stage IV pressure ulcer, which required a diverting colostomy with a recent right gluteal flap. He had comorbid conditions that would be expected to impair his ability to adequately perform pressure reliefs or perform skin checks. He had medical and skilled nursing needs requiring acute level care. He required the experience and expertise of trained clinicians to manage the patients complex wounds and to the begin sitting protocol that was requested, as well as to assist in directing his care. Given the extensive surgical procedures previously performed, there were few remaining surgical options; and if he succeeded with the acute level of care requested, he would be able to avoid further surgeries. He had already undergone a gluteal flap procedure, which limited his remaining surgical options. He ultimately had an additional surgery, which supports that care at a lower level could not have been effectively provided or met his medical, surgical, and rehabilitation needs. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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.
Appeal type: Experimental/Investigational
Decision: Overturned

A 60-year-old female enrollee has requested 72 weeks of pegylated interferon (Pegasys) for the treatment of the enrollees hepatitis C. Findings:  Two physician reviewers found that genotype 7 has been recently discovered as a distinct genetic make-up, and the response to standard combination therapy has not been established for genotype 7. Although some studies claim this duration of time to be typically adequate, other trials have demonstrated that longer courses of treatment have lower relapse rates. Infection with hepatitis C virus (HCV) genotypes 46 is distributed and studied less widely than genotypes 13. However, genotypes 46 are very common in geographic areas where chronic hepatitis C is highly prevalent. Response to treatment in patients with HCV genotype 6 may be at an intermediate level between that seen with genotype 1 and genotype 2 or 3. The optimal duration of treatment (24 versus 48 weeks) for HCV genotype 6 is unclear and currently under investigation. Although a couple of published studies by Yuen and colleagues and Hui and colleagues showed better sustained virological response in genotype 6-7 patients than genotype 1, the duration of therapy in these genotypes remains controversial and uncertain at this point. In this patients case, Pegasys treatment should be given for 48 weeks. This is likely to be more efficacious for treatment of this patient than the Health Plans proposed 24 weeks of Pegasys therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the lymph node. The American College of Radiology (ACR) states that in the case of a suspicious axillary lymph node, an ultrasound with needle biopsy is considered the most appropriate modality for investigation. MRI of the breast and axilla may be utilized to detect occult malignancy in the breast when an ultrasound guided biopsy of an axillary node detects malignancy. MRI does not have a role in surveillance of inflamed lymph nodes. Axillary lymphadenopathy after COVID vaccination is a well-documented phenomenon at this point. When the vaccines were initially deployed, the presentation of axillary adenopathy created diagnostic dilemmas and confusion, particularly in women and people with known cancers. In a study of adenopathy following Covid vaccination, Wolfson and colleagues noted that adenopathy may remain for several months, with one case demonstrating persistent axillary lymphadenopathy up to 43 weeks following a second dose of vaccination. In a review of recommendations from multiple societies regarding adenopathy following Covid vaccination, Brown and colleagues report that a common recommendation is a wait and see approach unless there is evidence for or suspicion of malignancy. In this case, the patient underwent biopsy which revealed non-malignant pathology.  In this clinical setting, given that a biopsy has eliminated the suspicion of malignancy, the requested service is not medically indicated. Therefore, MRI of the lymph node is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is 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 diagnostic radiology 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 24-year-old male enrollee has requested vertebroplasty / kyphoplasty for treatment of his back pain. Findings:  The physician reviewer found that the patient has multiple vertebral compression fractures that have been recalcitrant to conservative measures. Vertebroplasty and kyphoplasty have been shown to be very effective for immediate and lasting pain relief. Vertebroplasty has been used for over 20 years with excellent results. The submitted records indicate the patient has exhausted conservative treatment and he is an appropriate candidate for the proposed surgery.
Appeal type: Medical Necessity
Decision: Upheld

A 33-year-old male enrollee requested biweekly individual cognitive behavioral therapy (CBT). for medical treatment of his behavioral health condition.  Findings:  The physician reviewer found that the medical documentation submitted for review does not support the medical necessity of biweekly individual CBT appointments as the patient has not optimized the therapeutic interventions currently available to him. In addition the documentation provided did not include a treatment plan, interpretative summary and progress notes that would allow for assessing if the specific intervention and requested frequency of sessions was actively bolstering autonomy and resilience while mobilizing the patient towards enduring remission and averting treatment at a higher level of care.  As such, the requested services are not medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old male has requested counseling with a therapist who specializes in treating teenagers with families that have a hearing impairment for treatment of his anorexia nervosa.   Findings:  The physician reviewer found that based on review of the available records, this patient has complex parent-child relational dynamics, disordered eating behavior, distorted body image, anxiety, and depression. The current medical literature including the practice guidelines from the American Academy of Child and Adolescent Psychiatry (AACAP) and American Psychiatric Association (APA) do not provide guidance in this clinical circumstance. In addition, the patients records do not include an updated, comprehensive adolescent psychiatric evaluation which might support the requested intervention in this patients case. Given the lack of an indication for the requested counseling with a therapist who specializes in treating teenagers with families that have a hearing impairment, the requested services are not supported as medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for referral to a cardiologist.  Findings:  The physician reviewer found that records document that this patient presents with a history of transient ischemic attack (TIA). The patient has requested a referral to a cardiologist. However, there is a lack of documentation of symptoms, signs, or physical findings concerning for a cardiac abnormality requiring cardiologic consultation. A chest x-ray was interpreted to show no evidence of acute cardiopulmonary disease. In addition, the available reports do not include any laboratory studies revealing results that require further evaluation by a cardiologist. Moreover, the patient is under the care of a provider who did not recommend a cardiology consultation. For these reasons, the requested referral to a cardiologist is 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 board certified in internal medicine with subspecialty 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Evrysdi (risdiplam). Findings:  The physician reviewer found that this patients records document that her DNA test results were consistent with SMA. The patients provider has recommended treatment with Evrysdi. SMA is a disease characterized by degeneration of the anterior horn cells in the spinal cord and motor nuclei in the lower brainstem, which results in progressive muscle weakness and atrophy. Evrysdi corrects the splicing deficit of survival motor neuron 2 (SMN2), leading to increased levels of full-length SMN protein. The U.S. Food and Drug Administration (FDA) approved Evrysdi in 2020 for the treatment of SMA in patients two months of age and older. Given this support, the requested Evrysdi (risdiplam) is medically necessary for 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 neurology with subspecialty certification in vascular 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: Upheld

The patient has requested authorization and coverage for one-on-one (1:1) bedside sitter services, 24-hours per day, seven days a week. The medical literature supports a role for a bedside sitter as part of the management of patients with delirium, which is not present in this patient. The records provided for review document that the patient is able to communicate her needs with her providers. The patients current respiratory status is stable. She has a capped tracheostomy and there is no evidence of infection, coughing, or respiratory distress. She requires oral suctioning per documentation. Her treatment plan includes a 1:2 sitter. The documentation does not report extenuating factors to support a 1:1 sitter to maintain or improve her neuromuscular disease and her current medical condition. All told, the requested 1:1 bedside sitter services, 24-hours per day, and seven days a week are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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.