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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Botox injections into the bilateral hip adductors. The requested Botox injections into the bilateral hip adductors are not medically necessary to treat the patients medical condition. Van Lith and colleagues concluded, Bilateral botulinum toxin A treatment and subsequent stretching of the hip adductors may improve gait and reactive lateral stepping in patients with pure hereditary spastic paraplegia. Cioncoloni and colleagues reported, A meaningful improvement in walking performance can be obtained in chronic spastic patients after botulinum neurotoxin A injection into several muscles, specifically the hip adductors. Duran-Hernandez and colleagues noted, Osteoarthritis of the hip is a low-grade inflammatory disease of multiple etiology that has a limited conservative management and is insufficiently explored. The application of botulinum toxin type A produces in the applied muscle a temporary, delimitable and reversible flaccid paralysis, which applied in a strategic way achieves to reduce mechanical stress and pain. The authors concluded, The treatment with botulinum toxin type A provides a conservative and safe option for the management of symptoms and physical restraint caused by hip osteoarthritis.This patient has been treated for bilateral hip joint stiffness. She presented with tight hip adductors bilaterally, which are also painful. She underwent previous hip replacement surgery. More recently, she has been noted to have difficulty with tight hip adductors, with pain on attempted abduction. Per the records, hip abduction is only about 15 to 20 degrees in flexion. The hip adductor longus is tight bilaterally. She did not appear to have significant tightness of her gracilis. While there may be support for the use of these injections to treat certain disorders, there is limited published, large-scale, long-term peer-reviewed literature that shows this request to be an effective or safe treatment for the patients noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested Botox injections into the bilateral hip adductors are 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Otezla tablets for treatment of the enrollees chronic plaque psoriasis.  Findings: The physician reviewer found that the requested medication is medically necessary in this clinical setting.  In accordance with professionally recognized standards of care, Otezla is prescribed for treatment of chronic plaque psoriasis. In a letter, the provider stated that the patient has tried and failed other therapies but did well with the Otezla samples. Per the provider, the patient has tried Clobetasol and failed. Moreover, this patient is at child bearing age so treatment with methotrexate, cyclosporine, and acitretin are not recommended because of the serious complications these medications may cause with pregnancy. Otezla is a medication that is standard therapy for treatment of chronic plaque psoriasis. All told, the requested medication is medically necessary for treatment of this patients medical condition.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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni for 12 weeks for treatment of his hepatitis C virus. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. The current guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication regimen 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 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: Overturned

A 34-year-old female enrollee has requested for Raptiva injections for treatment of her psoriasis. Findings:  The physician reviewer found that there is no documentation that the patient was ever treated with methotrexate, cyclosporine, or acitretin.However, both acitretin and methotrexate are teratogenic and are contraindicated in women who are pregnant or who are likely to become pregnant. Given this patient's age and apparent desire for pregnancy, use of methotrexate and acitretin should be avoided.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 53-year-old male with a history of high cholesterol and LDL. He also has a family history of coronary artery disease. The patient took Zetia and his cholesterol and LDL came down. The patient has declined the use of statins on the basis he is concerned about the side effects including liver function problems and rhabdomyolysis. It appears the patient has never been tried on statins. The patient wishes to continue to use Zetia. The Health Plan has denied authorization for the requested medication on the basis it is not medically necessary.The Health Plans denial should be upheld. Based upon the information provided, it appears the patient has not been tried on statins. The relevant medical literature recommends statins as first-line therapy because of endothelial stabilizing effects and anti-inflammatory effects. Furthermore, not all patients experience side effects from statins. Though the patient expresses concern over rhabdomyolysis, this side effect is very rare. The patient should be tried on statins prior to pursuing medication alternatives. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested a blood pressure monitor for medical treatment of his high blood pressure.  Findings:  The physician reviewer found that the documentation submitted for review indicates the patient is being treated with a low dose of Cardizem. However, there is a lack of clinical documentation demonstrating the patient has poor control of his blood pressure. All told, the medical necessity of the requested services has not been established.
Appeal type: Medical Necessity
Decision: Overturned

A 27-year-old female enrollee has requested bilateral bunionectomy surgery for the treatment of her medical condition. Findings:  The physician reviewer found that bunion deformities are orthopedic deformities of the first metatarsophalangeal joint which result in a painful bump of bone medially as well as first metaphalangeal joint pain, due to misalignment of the joint.  Once formed, the deviated toe and joint will not correct without surgery.  Without correction, the bunion deformity has the potential to progress, possibly causing the second toe to overlap the first.  This creates the potential for increased friction and ulceration.  In this case, the progress notes show that the patient has suffered with painful bunions for many years.  These have been non-responsive to conservative care, including medications and wide footwear.  Podiatry records document skin irritation over the bunion deformity.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old female enrollee has requested for artificial intervertebral disc replacement for treatment of his cervical herniated disc. Findings:  Three physician reviewers found that there have been improvements in the safety of the procedure, and initial results offer much promise for the future. However, there remains a lack of information regarding the safety and efficacy over the long-term, and this remains an area of investigation. There is a lack of adequately controlled studies. Studies to evaluate these questions are still in progress, but have not yet been completed. The procedure continues to be the subject of study, and several questions of safety and efficacy remain.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Percocet. Findings:  The physician reviewer found that the American Society of Interventional Pain Physicians (ASIPP) state that to support an indication for opioid therapy, it is essential to have a physical diagnosis and information on inadequacy of multiple modalities of treatments including conservative, various other alternatives, and consultations if necessary. The guidelines note that these interventions include non-controlled substance therapy, physical modalities, behavioral interventions, interventional pain management techniques, and any other alternatives. The Centers for Disease Control and Prevention (CDC) guidelines state that providers should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. This patients imaging studies demonstrate mild osteoarthritic changes of the cervical and lumbar spine as well as the knees and hands. The patient has been treated with ibuprofen, Vicodin and Tylenol. The records do not report that the patient has exhausted non-pharmacologic modalities including physical therapy and interventional pain treatments. The records do not include patients pain scale scores or treatment goals as part of an opioid therapy plan as recommended by the CDC guidelines. Based on the medical records provided for review and the current medical literature, the request for Percocet is not medically necessary for treatment of this patients pain. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with 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.
Appeal type: Urgent Care
Decision: Upheld

A 43-year-old female enrollee has requested for emergency services required on an emergent basis. Findings:  The physician reviewer found that an emergency is the sudden onset of symptoms of such severity that a prudent layperson would believe her health to be in jeopardy without immediate medical attention. This patient had developed back pain gradually over the course of several days. She had a history of prior back pain. The patient denied any symptoms of an acute neurologic emergency, such as bladder dysfunction or paralysis. She appeared in mild distress, and her examination was significant only for mild paraspinal muscle tenderness. The patient required only oral pain medication. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an urgent or emergent basis
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee requested authorization and coverage of spinal reconstruction surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees back 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 procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 25-year-old male has requested coverage for past residential treatment center (RTC) services for treatment of his schizoaffective disorder, bipolar type.   Findings:  The physician reviewer found that based on review of the available records, after approximately one month of treatment, the patients symptoms were improving. He remained cooperative with treatment throughout his admission, and was never a behavior problem. He continued to exhibit psychotic thinking, but the patient had displayed psychosis for many months prior to admission. The main purpose for this hospitalization appeared to be medication trials to improve his symptoms. The records indicate that by the date at issue, the patient was fully compliant with his medications and was participating in his own treatment. As of this date, he could have continued to receive medication management and group and individual therapy at a lower level of care without jeopardizing his outcome.
Appeal type: Experimental/Investigational
Decision: Upheld

A 49-year-old female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees pain and headaches.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for hydrocodone-acetaminophen (Norco) 10-325 mg oral tablets (until surgery). The Federation of State Medical Boards guidelines state that the use of opioid therapy depends on a providers 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. In this case, the patient has chronic low back pain with lumbar radiculopathy status post two previous spine surgeries. He was scheduled for a lumbar fusion procedure, which was postponed due to COVID-19 restrictions. Treatment has included a multimodal strategy of medication management. He underwent an epidural steroid injection, which reportedly provided four hours of pain relief. His provider has recommended physical therapy and treatment with pain management. The patient is noted to have a prior diagnosis of opioid use disorder and cannabis dependence, with a recent positive toxicology report for THC. The current national guidelines do not support treatment with Norco in this patients case, as the benefits of opioid therapy do not outweigh the risks of self-prescribing behavior given his previous history of chemical dependence. All told, the requested hydrocodone-acetaminophen (Norco) 10-325 mg oral tablets are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology with 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.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a one-year-old male enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that the requested speech therapy is medically necessary for treatment of this patient.  Speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success. Identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best. Preschool-aged children with speech and language delay may be at increased risk for learning disabilities once they reach school age.  The long-term consequences of speech and language delay may be substantial. Law and colleagues noted that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  Bernhardt and Major reported that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for children with a history of severe phonological impairment.  This patient has significant speech and language delay, particularly in the area of language expression. His speech and language deficits negatively impact his ability to play and communicate effectively. Studies have shown that speech and language therapy can result in significant improvement in such children. All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old male enrollee has requested and coverage for Taclonex for treatment of his psoriasis. Findings:  The physician reviewer found that this patient has responded well to Taclonex in the past. Months later, he experienced recurrent symptoms necessitating Kenalog IM. He was subsequently prescribed a very potent steroid (clobetasol) with Dovonex cream. He experienced some improvement. Taclonex is medically appropriate and indicated in this setting.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a seven-year-old male enrollee has requested for speech therapy for treatment of his speech delay.   Findings:  The physician reviewer found that this patient has a significant congenital language handicap that has been resistant to nearly four years of speech therapy. Despite some gains, he continues to have significant delay in the initiation of speech, which is a congenital dysfunction. He is beyond the age when most grammatical dysfunction shows spontaneous improvement.
Appeal type: Medical Necessity
Decision: Upheld

A 21-year-old male enrollee requested vagus nerve stimulation for medical treatment of his seizure disorder.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. According to the documentation submitted for review, the patients seizures have been treated with a new combination of medications. While vagus nerve stimulation is useful for refractory seizures, it is not indicated in patients who respond well to medical treatment. Based on the clinical documentation submitted for review, the medical necessity of the requested services has not been established in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement for wilderness therapy at Evoke Second Nature Entrada. Current medical literature suggests that wilderness therapy may be an effective treatment option for a wide variety of adolescents, including youth with substance abuse problems and adolescents suffering from depression and various other clinical disorders, and improve interpersonal relationships. However, there is a lack of evidence supporting the claim that outdoor behavioral healthcare programs are superior to standard therapies as a treatment intervention for adolescent substance use and mental health disorders. Few studies directly compare outcomes of outdoor behavioral healthcare programs to other therapeutic interventions. Dobud and Harper note that in a scoping review of direct comparison trials in adventure therapy, only 13 studies met the full inclusion criteria. The authors found few significant differences to isolate specific therapeutic factors. While literature on outdoor behavioral healthcare programs suggest that participants show some level of improvement on behavioral health outcomes, the results are not conclusive and there is a lack of randomized controlled trials or well-designed cohort studies that would allow for causal conclusions about the impact of outdoor behavioral healthcare programs. In this clinical setting, there is a lack of data to support the claim that outdoor behavioral healthcare programs were more effective than other therapies. Therefore, wilderness therapy at Evoke Second Nature Entrada was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the wilderness therapy at Evoke Second Nature Entrada at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry 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.