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

A 48-year-old male enrollee has requested Botox injections for treatment of his torticollis secondary to spastic dystonia, dysphagia, and muscle spasm.  Findings:  The physician reviewer found that cervical dystonia is identified when there is uncontrolled muscle spasm, often associated with tremor, altered posture, altered mobility, and pain. Torticollis is a fixed or dynamic tilt, rotation or flexion of the head and/or neck. The type of torticollis can be described depending on the positions of head and neck. This patients clinical documentation is consistent with a diagnosis of cervical dystonia, with possible orofacial dystonia as well. Botox is FDA approved for cervical dystonia, and is considered a first-line therapy. Botox is therefore appropriate and medically necessary for treatment of this patients dystonia.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested tramadol for treatment of her medical condition. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the medication at issue. The American College of Rheumatology (ACR) list both non-pharmacologic and pharmacologic treatments for osteoarthritis pain of the hand, hip, and knee. The recommendations include both nonsteroidal anti-inflammatory drugs (NSAIDs), both oral and topical, and tramadol for the treatment of hand osteoarthritis. The recommendations specifically exclude opioid analgesics for the treatment of hand osteoarthritis. For osteoarthritis of the hip and knee ACR states, Pharmacologic modalities conditionally recommended for the initial management of patients with knee [osteoarthritis] OA included acetaminophen, oral and topical NSAIDs, tramadol, and intraarticular corticosteroid injections; intraarticular hyaluronate injections, duloxetine, and opioids were conditionally recommended in patients who had an inadequate response to initial therapy. In no instance were opioid analgesics recommended by ACR prior to tramadol. In addition, Koopman and Moreland note that tramadol does not have significant addictive tendencies and therefore have a lower potential for abuse than opioid analgesics.  In this case, the patient is doing clinically well on tramadol and there is no medical basis requiring that she switch treatment to an opioid analgesic. The Health Plans requirement to switch from a clinically effective non-opioid treatment such as tramadol to extended-release opioid analgesic is contrary to the patients best interest. In sum, tramadol was and is medically necessary for the treatment of this patients osteoarthritis.  Final Result:  The reviewer determined that the medication at issue was and 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 rheumatology 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 51-year-old female enrollee has requested a laparoscopic sleeve gastrectomy for treatment of her morbid obesity.  Findings:  Two physician reviewers found that weight-related comorbid conditions include hypertension, diabetes and sleep apnea. The patient has a history of hypothyroidism and is on medication. Cardiac clearance was obtained. A dietary evaluation did not reveal any barriers to surgery. A behavioral evaluation did not reveal any obvious barriers to surgery. The patient has failed dietary efforts in the past. This patient has morbid obesity, has failed reasonable weight loss attempts and does not have any obvious metabolic, medical, dietary or behavioral barriers to surgery. Thus, she meets all generally accepted criteria for bariatric surgery.  A laparoscopic sleeve gastrectomy is an appropriate primary treatment of morbid obesity in the well-selected patient.  The current medical literature has documented the safety and efficacy of this procedure.  Therefore, in this patients case, the requested laparoscopic sleeve gastrectomy is likely to be superior over all other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cialis 5 mg for treatment of the enrollees erectile dysfunction. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The phosphodiesterase inhibitor potential to prolong QT interval and adversely interact with use of ziprasidone to potentiate cardiac arrhythmia is a theoretical risk not reported in the ambulatory setting.  Additionally, this is a risk which can be monitored by electrocardiogram and other techniques to assure early detection.  While the risk has been discussed with Levitra, it has not been discussed with Viagra.  Both Levitra and Viagra have been offered by the Health Plan.  There is a lack of support for the requested medication in this clinical setting.  All told, the requested Cialis 5 mg is not medically indicated 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 urology 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 44-year-old female enrollee requested authorization and coverage of gastric banding. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees morbid obesity. Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy depending upon the results of a psychological evaluation. One of the three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy depending upon the results of a psychological evaluation the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 6-year-old male enrollee has requested psychotherapy provided by a clinical psychologist (doctoral level provider) for treatment of the enrollees attention deficit hyperactivity disorder (ADHD) and emotional regulation issues. Findings:  The physician reviewer found that while the standard of care and generally accepted practice for the treatment of childhood ADHD is medication, there are also concomitant issues that involve behavior, learning and psychosocial issues that need to be addressed in a comprehensive treatment plan that includes psychotherapy with parent and child, involvement of teachers and a firm alliance to make sure that consistent coordinated efforts are applied across settings. Psychotherapy is medically appropriate and necessary in light of the patients diagnosis of ADHD and symptomatology suggestive of depression and/or adjustment disorder. However, it is not medically necessary that the patients therapy be provided by a clinical psychologist, doctoral level provider. A therapist who is trained in the treatment of children with ADHD and/or emotional issues should have appropriate expertise to help promote the development of emotional and behavioral management skills in this patient. Such expertise is not unique to a doctoral level provider.  Accordingly, although once weekly psychotherapy is medically necessary for treatment of the patients medical condition, psychotherapy with a clinical psychologist (doctoral level provider) is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for removal of fibroma on tongue for the treatment of the enrollees fibroma. Findings:  The physician reviewer found that the physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services. Clinically, benign lesions of the tongue are usually asymptomatic and may appear in the majority of circumstances as a result of minor trauma. The usual management of small lesions less than 5 mm is careful observation, unless there is functional impairment. Per the medical records, this patients lesion measures only approximately 3 mm.  Although the patient complained of minor bleeding, this does not qualify as an impairment of function. The records do not document that chewing, eating, swallowing or taste were impaired from the presence of the tongue lesion. The patient reported that the lesion affected her speech and work as a music teacher. However, the degree of impairment was not specified.  The submitted records do not demonstrate that the patient underwent a speech evaluation to determine the degree of functional impairment. The clinical notes from the provider did not indicate that the patient had any form of dysarthria or speech impairment as a result of the lesion. The current medical evidence does not support removal of the small lesion in this clinical setting. All told, removal of fibroma on tongue is not medically necessary for the 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 otolaryngology 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 is a 64-year-old woman with long-standing plantar fasciitis. The patient has tried and failed conservative treatment including medication, therapy, and two cortisone injections. A request has been made for authorization for extracorporeal shock wave therapy (ESWT), which the Health Plan has denied.ESWT has been established as a treatment for plantar fasciitis in patients who do not respond to conservative measures. It is a non-surgical means of alleviating pain and has an acceptable success rate. This patient has clearly failed conservative treatment. She is an appropriate candidate for ESWT and as such, the procedure should be authorized. Therefore, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right knee injections with Orthovisc. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. There is a lack of support for the requested services in this clinical setting. Per the current medical evidence, hyaluronic acid injections in the knee are recommended as a possible option for patients with severe osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. While medial and/or lateral compartment osteoarthritis is a recommended indication, there is insufficient evidence for other conditions including patellofemoral arthritis, chondromalacia patella, patellofemoral syndrome (kneecap pain), or osteochondritis dissecans. The medical literature generally supports the use of hyaluronic acid injections for chronic moderate symptomatic osteoarthritis of the knee but states that application in sports-related chondropathy has yet to be fully assessed. The ideal indication in the knee appears to be moderate femorotibial osteoarthritis without swelling.  This patient presents with complaints of right knee pain, swelling, and instability with difficulty in activities of daily living. Clinical examination findings have been generally consistent with x-ray findings of very mild spurring at the medial compartment, no significant joint space narrowing, and minor spurring around patella. There is evidence of long-term nonsteroidal anti-inflammatory drug use, prior physical therapy, and home exercise program, with reported insufficient benefit. However, the records documented mostly anterior right knee pain with a diagnosis of bilateral knee patellofemoral chondromalacia patella/osteoarthritis. Evidence-based medical guidelines and literature do not support the use of Orthovisc injections for patellofemoral osteoarthritis, or for very mild femorotibial osteoarthritis. Therefore, the requested right knee injections with Orthovisc 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 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:  An enrollee has requested Harvoni for 24 weeks for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that per the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), both of the regimens listed below are recommended for treatment-experienced genotype 1 patients with cirrhosis as a Class I, Level A rating. The patient is requesting daily fixed-dose combination of ledipasvir/sofosbuvir for 24 weeks is a recommended regimen for patients in whom prior peg-interferon and ribavirin treatment has failed. The Health Plan recommends the preferred therapy of daily fixed-dose combination of paritaprevir/ritonavir/ombitasvir plus twice-daily dosed dasabuvir and weight-based ribavirin for 24 weeks is an alternative regimen for patients with compensated cirrhosis, in whom prior peg-interferon and ribavirin treatment has failed. Based on the documentation submitted for review, the patient is not ribavirin-ineligible, and can be treated with Viekira Pak plus ribavirin. As such, the medical necessity for Harvoni for 24 weeks has not been established in this clinical setting.  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 gastroenterology 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 and conservator of a 40-year-old female enrollee has requested transfer to an out-of-network facility for brain rehabilitation following the enrollees traumatic brain injury. Findings:  The physician reviewer found that there is no evidence that intensive neurological rehabilitation has a role in the care of patients who are unresponsive. The intensity and effective duration of such therapy is debated even for patients less seriously injured. The medical care for patients with severe head injury is a serious and complex matter. The Health Plans recommendations for consultation are appropriate and helpful, but most of the patients needs are custodial in nature, as there is no evidence or expectation that a comprehensive neuro-rehabilitation program will benefit an unresponsive person. There is no defined medical therapy that can be expected to improve outcome although anecdotal reports abound. Unfortunately, these reports do not provide a guide to a coherent systematic approach that can be expected to provide any benefit. At any rate, medical or pharmacological interventions designed to improve cognitive function can be employed at the patients current residence, especially in consultation with specialists as the Health Plan has suggested. There is no medical necessity for a move to a comprehensive center.  Finally, examination of her limbs found she was receiving satisfactory care with splinting, medication, and passive range of motion exercises for joint mobility.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intravenous immune globulin infusion. The submitted documentation fails to demonstrate the medical necessity of the requested services. Multiple sclerosis is the most common immunologic neurological disorder of young adults. While this patient has not responded well to Copaxone, the research indicates that interferon beta-1a can be an acceptable option in the postpartum period and may be appropriate in the setting of breastfeeding. Pulse intravenous steroids have also been shown to be effective in a prophylactic and symptomatic management setting. Studies supporting intravenous immune globulin are limited at best and do not support improved outcomes when compared to other treatment options. A recent United Kingdom consensus guideline on pregnancy in multiple sclerosis states immunoglobulin should not be given to prevent post-partum relapses. Additionally, concurrent breast feeding is believed to be safe with use of interferon beta-1a and steroids. Studies and guidelines supporting intravenous immune globulin (IVIG) for the prevention of post-partum relapses are limited at best and guidelines do not endorse its use. Therefore, the requested intravenous immune globulin is not medically necessary for the 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A forty-three year-old female with profound anorexia and bulimia is requesting authorization for residential treatment services.  The patient had failed partial hospitalization level of care and then entered residential treatment.Reviewers FindingsThe reviewing physician found that the submitted clinical information demonstrated the patient was too sick to be cared for in a partial hospitalization program and could not return home to an unsupervised situation.  Therefore, the reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for earlobe repair. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition and are not reconstructive in nature. Findings: The submitted documentation does not support the medical necessity for the requested earlobe repair. There is evidence of a mildly elongated left earlobe piercing but there is no complete split visible. The provider noted normal external left ear and an otherwise normal appearing earlobe. Based on the documentation provided and review of the photographs, they have not demonstrated that the mildly elongated earlobe is contributing to a functional impairment. In addition, the earlobe appears relatively normal except for the mild elongation of the piercing. Accordingly, the requested earlobe repair is not supported as medically necessary for treatment of this patients medical condition.With regards to whether the requested services are reconstructive in nature, the records provided do not support that the requested earlobe repair meets the criteria under the expanded concept of medical necessity. Earlobe reconstruction may be indicated for cases of a complete cleft or a severely elongated piercing site, generally from trauma. In this patients case, the functional concerns reported by the patient are unlikely to be addressed with a partial earlobe correction and the findings are not consistent with a significant earlobe deformity. In addition, the patient has a relatively normal appearing left earlobe. The patient may have experienced a minor trauma associated with the elongated ear piercing, but based on the photographs and the records, this has not produced a significant abnormality. Moreover, there is insufficient evidence that a functional impairment is related to the earlobe elongation. As such, there would not be more than a minimal improvement that would be gained with an earlobe correction. For these reasons, the requested earlobe repair is not reconstructive in nature.Final Result: The reviewer determined requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic 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 50-year-old female enrollee requested substance abuse residential level of care for medical treatment of her behavioral health conditions.  Findings:  The physician reviewer found that in this case, the patients substance abuse necessitated specialty services.  However, the patient had not failed any less restrictive interventions, such as intensive outpatient programming or partial hospitalization with supportive sober living in the community, during the episode of illness.  Additionally, the documentation provided did not include a treatment plan, progress notes or a clinical rationale supporting the need for residential placement as opposed to treatment at a lower level of care.  Considering the clinical presentation and patient history, substance abuse residential level of care was not medically indicated for the treatment of this patient.