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

Nature of Statutory Criteria/Case Summary: An enrollee has requested resumption of skilled nursing facility (SNF) services including rehabilitation with daily physical therapy for treatment of the enrollees hemiplegia and hemiparesis. Findings: The physician reviewer found that the functional impairments due to acquired brain insults such as intracerebral hemorrhage can improve with time including natural recovery processes, but are also amenable to rehabilitation interventions (Kreisel, et al; Manno). The role of inpatient rehabilitative care for patients with significant functional deficits in this setting is well-established in the medical literature (Dewey, et al; Langhorne, et al). Despite treatment, deficits can remain severe. Functional dependency following intracerebral hemorrhage is high (Kuramatsu, et al; van Asch, et al). In the present case, the patient sustained a right basal ganglia hemorrhage. His cerebral pathology has been accompanied by significant functional impairments. He underwent extensive inpatient rehabilitation. The records document that the patient plateaued at a level where he was non-ambulatory and dependent for care. He has been at a custodial level of care. There are no indications that there have been recent significant changes in his condition, such that participation and progress with therapies in an inpatient setting would be required. Further rehabilitative services may be considered going forward, but these services can be provided in a community setting, with custodial level services for his basic self-care. Caregivers should have had sufficient time to undergo the training to provide custodial level care in the home setting. If the current caregivers are unable to provide care, care in a custodial level facility would be an appropriate alternative. Overall, there are no documented ongoing skilled nursing needs such as complex wound care, initiation of self-care related to enteral feeding, or ostomy care requiring ongoing inpatient care. Thus, the requested resumption of SNF services including rehabilitation with daily physical therapy is not supported as medically necessary for treatment of this patients medical condition.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 and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old male enrollee has requested a computed tomography angiography (CTA) to detect coronary artery calcium scoring (calcification) for an evaluation of his risk for coronary artery disease. Findings:  Two physician reviewers found that CTA for detection of coronary artery calcification is not an accepted screening or confirmatory test in this patient subset and is not a medically appropriate alternative for other conventional screening tests that are within the standard of care such as treadmill stress testing. CTA is also not a medically indicated substitute for coronary angiography, as CTA would not be able to accurately confirm or exclude important coronary obstruction. The use of CTA in the diagnosis and prognosis of coronary disease in this patient subset has not been shown to be superior to the standard treatment protocol in this setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for oxycodone HCL solution. Findings:  The physician reviewer found that the stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative and the non-palliative settings). It is unclear from the documentation provided as to why this patient is switching from a capsule to a solution despite no complication to the current medications. Nevertheless, in this case not all non-opioid treatment options have been utilized. There is no mention that this patient has completed behavior therapy despite much research to support its use. It is also reasonable to consider alternatives to opioids and to wean the patient to a lower dose of opioids or even off opioids. Furthermore, there is no objective treatment goals for pain and function noted for the requested medication. The Centers for Disease Control and Prevention (CDC) states regarding co-prescription of opioids with benzodiazepines, epidemiologic studies suggest that concurrent use of benzodiazepines and opioids might put patients at greater risk for potentially fatal overdose. The CDC also states clinicians should avoid prescribing opioids and benzodiazepines concurrently whenever possible. The CDC also states when opioids are started, clinicians should prescribe the lowest effective dosage. In addition, multiple minimal requirements for opioid prescribing have not been performed and the need to use them as the primary medication treatment strategy for pain has not been established. Finally, not all non-opioid medications classes have been optimized or tried. For all these reasons, oxycodone HCL solution is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication solution 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 sub-specialty 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested mental health intensive outpatient program (IOP) services for treatment of her medical condition. Findings:  The physician reviewer found that as in all conditions, the least restrictive level of care is preferred, and the determination of the ideal care setting is best made by the providers most familiar with the clinical situation and treatment needs. With that in mind, both the patients psychiatrist and therapist have recommended continued treatment at the IOP level of care. During her IOP programming thus far, the patient has been engaged in active treatment using evidence-based therapies delivered in accordance with an individual plan of care targeting her conditions. The IOP setting is reasonably expected to both improve the patients condition and prevent a more serious episode of illness.  The IOP setting represents a safe and appropriate placement consistent with accepted medical practice in this setting.  As such, the services at issue were and are medically necessary for treatment of the patients behavioral health condition.   Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla for treatment of the enrollees psoriasis. Findings:  The physician reviewer found that records do not document a contraindication to the use of methotrexate, cyclosporine, or acitretin, and failure or contraindication to treatment with Enbrel and Humira. The patinet's past positive PPD does not appear to represent active or latent tuberculosis disease given his recent negative QuantiFERON Gold tuberculosis testing. The medical records indicate that the patient may be considered for treatment with Cosentyx, another injectable biologic agent, demonstrating that usage of biologics would not be contraindicated in 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee requested authorization and coverage of continued psychotherapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees depression.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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the breasts for evaluation of the enrollee, who has a family history of breast cancer. Findings:  The physician reviewer found that there is a lack of support for the requested services in this clinical setting.  MRI studies of the breast are highly sensitive, but have a relatively low level of specificity.  The literature does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound.  In some studies, the specificity of breast MRI has been reported to be as low as 37%.  In other words, it is common for an MRI report to state that there are subtle abnormalities that are not indicative of definite tumor, and a follow-up MRI is subsequently recommended.  Questionable MRI findings often lead to unnecessary biopsies.  This patient has consistently stable mammograms, which is probably the best indication that she does not have tumor.  The most valuable tool in interpreting a mammogram is a comparison with an older mammogram, especially when there are no palpable masses.  There is a lack of evidence to support the use of MRI as a surveillance tool rather than conventional mammography.  In this patients case, despite her family history, she does not meet the criteria for being at high-risk for developing breast cancer, which is as defined as having a 20-25% likelihood of developing the disease.  There is insufficient data available to support the use of breast MRI in this clinical setting.  Therefore, the requested MRI of the breasts is not medically indicated for the evaluation of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician 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 63-year-old male enrollee has requested the medication Levitra for the treatment of the enrollees erectile dysfunction (ED). Findings:  The physician reviewer found that although the specific cause of the patients ED has yet to be fully determined, both polyneuropathy and diabetes mellitus may lead to erectile dysfunction. The patient has been definitively diagnosed with polyneuropathy, and a diagnosis of diabetes is very likely given the current clinical evidence. He has had a good clinical response to Levitra, and the medication has been prescribed by his attending physician to treat his medical problem.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a male enrollee requested weekly private therapy services for medical treatment of the enrollees attention deficit/hyperactivity disorder (ADHD).  Findings:  The physician reviewer found that this patients records indicate that he is being managed appropriately and is showing a marked improvement in both home and school as a result. The plan is to continue medication management and family therapy. Any further behavior problems that occur at home can be adequately addressed within the family therapy sessions. All told, the requested weekly private therapy services are not 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 reimbursement, authorization and coverage for residential treatment services. The submitted documentation supports the medical necessity of the patients residential treatment services provided and going forward. American Psychiatric Association practice guidelines for substance use disorders recommend that residential treatment is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use. To qualify for residential treatment, patients must also lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. While the purpose of detoxification is to make the patient psychically stable and safe, rehabilitation is the essential component that should follow detoxification to help the patient maintain sobriety and reduce risk of relapse. In this case, medical records reflect that the patient has had multiple relapses and has recurrent depression. The patient has exhibited violent and angry behavior toward partners and family members. Furthermore, records reflect a recent overdose. The patient is therefore documented to be at high risk for relapse. Under these circumstances, residential treatment services are in accordance with generally accepted standards of medical practice and are clinically appropriate for the patient's medical condition. Accordingly, all of the residential treatment services provided and going forward, were medically necessary to treat the patients condition.Final Result: The reviewer determined that the services in issue and ongoing services were medically necessary for treatment of the patients medical condition. Therefore, the patient should be reimbursed for the services in issue, and the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for kyphoplasty.Findings:  The physician reviewer found that the patient has a lumbar compression fracture with complaints of progressive pain despite six weeks of conservative care including bracing and medications. The patients provider has recommended treatment with kyphoplasty. As noted in the peer-reviewed medical literature, kyphoplasty is supported by current high-grade evidence to be more effective at controlling pain than nonsurgical treatment options in this patients clinical setting. In addition, kyphoplasty is supported by recent large-volume studies on patients with simple osteoporotic fractures (Papanastassiou, et al.; Ma, et al.). Overall, there is adequate support for kyphoplasty to increase this patients kyphosis angle that has not improved despite nonsurgical management. For these reasons, the requested kyphoplasty is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested kyphoplasty 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 orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery 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: Experimental/Investigational
Decision: Overturned

The patient has requested authorization and coverage for Rezum water vapor therapy. This patient presents with moderate bladder outlet obstructive complaints. The patient has a symptom score of 15 with complaints of nocturia and urgency. The records document that he was placed on behavioral modification with decreased caffeine intake and was treated with tamsulosin with some improvement in his symptoms. He was also noted to have an elevated prostate specific antigen (PSA) of 8.0. The patient underwent transrectal ultrasonic guided biopsy of prostate which revealed an approximately 36-gram prostate. The provider recommended treatment with Rezum water vapor therapy. In the current peer-reviewed medical literature, found that Rezum provides early effective and durable relief of benign prostatic hyperplasia symptoms with preservation of sexual function in subjects followed up for three years and is applicable to treatment of the median lobe and hyperplastic central zone tissue. As this patients condition has not substantially improved with behavior modification and tamsulosin, the requested Rezum water vapor therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three 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:  One reviewer is board certified in urology and is actively practicing. One Reviewer is board certified in urology and is actively practicing.  One Reviewer is board certified in urology and is 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: Experimental/Investigational
Decision: Upheld

A 36-year-old female enrollee has requested bronchial thermoplasty for treatment of her severe persistent asthma.  Findings:  Two physician reviewers found that this patients records lack documentation of recent severe asthma exacerbations, emergency room visits, hospitalizations, or intubations within the past two years. These are the categories that would benefit from bronchial thermoplasty. In the absence of documentation of poorly controlled asthma while on inhaled long acting bronchodilators and inhaled high potency corticosteroids, the requested bronchial thermoplasty is not likely to be more beneficial than standard therapies including omalizumab.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old female enrollee has requested for Lyrica for treatment of her trigeminal neuralgia. Findings:  The physician reviewer found that despite the fact that Lyrica is not officially approved for the indication of trigeminal neuralgia by the Food and Drug Administration, there is an extensive body of literature and treatment guidelines published by the American Academy of Neurology. In addition, there is clinical experience supporting the use of Lyrica for this condition as a very effective medication. In this patients particular case, she has failed trials with previous medications and was started on treatment with Lyrica in a medically appropriate clinical decision, with the support of all of the patients prior clinical success in the management of her pain.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for complete breast ultrasound. This patient with dense breast tissue has been evaluated with breast tomosynthesis examinations on multiple occasions over the last year. Per Kaplan, automated complete breast ultrasound has become a viable option for providing widespread ultrasound screening to fulfill this newly developing demand for adjunctive breast cancer screening. One disadvantage with breast magnetic resonance imaging (MRI) is that the studies of the breast are highly sensitive but have a relatively low level of specificity. Overall, the utility of complete breast ultrasound in this patient with dense breast tissue has been demonstrated in the medical literature (Shin, et al.; Kim, et al.; Giger, et al.). For these reasons, the complete breast ultrasound was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the complete breast ultrasound was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The representative of an 18-year-old female enrollee has requested a sub-acute residential eating disorder program for the treatment of the enrollees eating disorder. Findings:  The physician reviewer found that though the patient has suffered from something of an eating disorder and dysphoria, her symptoms appeared to be relatively middling, as compared to someone typically deemed in need of something as intensive as residential treatment.  No doubt there are struggles at hand for her, but given how relatively low-level they are, it is unclear why her treatment could not have been approached on an outpatient basis (be it Intensive Outpatient Treatment per se or Partial Hospitalization).  As shown in the note submitted, there is no conveyance of anything particularly striking that would fall outside of the bounds of conventional outpatient care.  In addition, none of the subsequent chart notes convey anything striking.  Therefore, I find that there is no medical indication for residential treatment beyond the date in question and recommend upholding the Health Plans denial.