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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Copaxone Syringe 40 mg/mL. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. Mitsikostas and colleagues have reflected that glatiramer acetate (GA), an FDA-approved therapeutic equivalent to Copaxone, is an effective treatment for multiple sclerosis with a side effect profile that is better than comparable treatments for multiple sclerosis. In their comparison of therapies, there was no indication of an advantage of brand type over generic type. In this case, while the patient has noted a concern for potential side effects related to the generic equivalents to Copaxone, there is no indication to favor brand name Copaxone over its therapeutic equivalents. The submitted records reflect that the patient has been diagnosed with multiple sclerosis (MS) and was started on a generic equivalent to Copaxone and has not demonstrated any side effects or allergies related to the medication. Under these circumstances, Copaxone Syringe 40 mg/mL is not medically necessary for the patients medical condition.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 neurology, with subspecialty certification in pain 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.
Appeal type: Experimental/Investigational
Decision: Overturned

A 60-year-old female enrollee has requested the real time heart monitor study for evaluation of her heart palpitations.  Findings:  Two physician reviewers found that when a patient is being evaluated for syncope or presyncope, extending the period of monitoring can increase the incidence of symptomatic events to approximately 50% at three days and 75% at 5 to 21 days. The diagnostic value of ambulatory monitoring depends on a number of variables. As an example, attention has been drawn to the differences between hospital inpatients and outpatients with ventricular arrhythmias. One study found that 6.3% of 306 hospitalized patients complained of symptoms of ventricular arrhythmias (Zeldis, et al). These complaints correlated with causal arrhythmias detected by 24-hour ambulatory electrocardiography in 95% of patients. Complaints occurred more frequently in 278 outpatients, but these symptoms were less likely to correlate with a causal arrhythmia. Given this patients symptoms, it was reasonable to place a cardiac event monitor. Thus, the real time heart monitor study provided from the time period specified was likely to have been more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for a transthoracic echocardiogram. Echocardiography is appropriate to evaluate cardiac structure and function when a patient presents with symptoms of suspected cardiac etiology including, but not limited to, chest pain, shortness of breath, or recent embolic event, or has palpitations with symptoms or signs of cardiovascular disease, for example, an abnormal physical examination or electrocardiogram. In this case, the patient has new onset of symptoms, including shortness of breath and palpitations in the past six months. A previous echocardiogram documented mild mitral insufficiency. Given this patients change in symptoms, abnormal prior imaging, and that the prior study is over a year old, repeat echocardiography is medically indicated. Therefore, a transthoracic echocardiogram is medically necessary for the evaluation 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 internal medicine with sub-specialty 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: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for a six-month Dialectical Behavior Therapy (DBT) program. Findings:  The physician reviewer found that The submitted documentation does not support that the requested services are medically necessary. DBT is typically used for individuals with a diagnosis of borderline personality disorder. DBT is used to help individuals with emotion regulation issues, instability of affect, and interpersonal problems. In this case, the most recent progress notes from the patients psychiatrist and her therapist indicated that the patient appeared to be functioning well. These notes do not indicate that the patient was experiencing any suicidal ideation. The patient reported that her mood was stable. Her impulse control was noted to be good. The progress notes did not reflect mood swings or other impulsive behaviors. The progress notes indicated that the patient might have received DBT in the past with equivocal results. The submitted records do not indicate that the patient had been diagnosed with borderline personality disorder. The progress notes do not indicate that the patient was suffering from symptoms that would typically be managed by DBT. Major depressive disorder and generalized anxiety may be treated with therapies other than DBT. Under these circumstances, the requested six-month Dialectical Behavioral Therapy (DBT) program is not medically necessary to treat the 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 psychiatry, with subspecialty certification in child and adolescent psychiatry, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 16-year-old male with a history of depression, and bipolar disorder as well as drug use. He has attempted suicide twice within a four-month period. His medications include Depakote, Effexor, Dilantin, trazodone, and vitamin E. Psychological testing was performed to assess his risk of future suicide attempts. The Health Plan has denied coverage for the services at issue citing a lack of medical necessity.Psychological testing is not medically necessary to assess suicidal risk. Furthermore, such testing is not needed in order make or confirm a diagnosis of mood disorder. As such, there was no clinical indication for the psychological testing at issue. Therefore, I have determined that the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 5-year-old male enrollee has requested  for an ultra-light wheelchair for treatment of his cerebral palsy. Findings:  The physician reviewer found that this non-ambulatory patient will likely remain non-ambulatory and will require supportive wheelchairs throughout his lifetime. The  literature also shows that transportation load is non-variable and a constant, nearly daily need for children with cerebral palsy. The literature also notes that transportation safety depends on adequate restraints and support which would require an ultra-light wheelchair to have the supportive system recommended by the patients physical therapist.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested authorization and coverage for foot inserts (Foot, Insert, Removable, Molded to PT model, UCB Type, Berkley Shell  Code L3000). The health plan has denied this request as not medically necessary.  A review of the records indicates the enrollee was seen for follow-up of long-term right foot pain.  He reported that he had done well with orthoses, but he needed a new pair as the previous orthotics had worn out.  The use of orthotics had helped him avoid surgery.  Physical examination of the right foot demonstrated mild local edema to the plantar/central forefoot, mild tenderness of the second metatarsal head plantarly with direct pressure, flexor contractures of the second and third toes with medial deviation at the metacarpophalangeal (MP) joints, as well as dorsal subluxation of the second MP joint.  As the enrollee continued to do well and was not interested in surgical correction, updated custom functional orthoses were recommended.  According to current peer-reviewed medical literature, when hammertoes cause significant pain or interfere with gait, surgical correction is required. For less severe symptomatic cases, hammer toe pads, buddy taping, shoes with a roomy toe box, and various orthotics and forefoot padding may offer some pain relief.  The initial treatment for metatarsalgia consists of metatarsal pads.  If metatarsal pads are ineffective, small observational studies suggest that customized orthotics designed to unload the distal metatarsals and distribute plantar pressure more evenly substantially reduce pain and allow patients to increase their walking.  Surgical referral is a last resort for metatarsalgia.  The enrollee has chronic foot pain, metatarsalgia, and hammertoe.  Supporting examination findings included edema to the plantar/central forefoot, tenderness of the second metatarsal head, and contractures of the second third toes.  The enrollee reported significant benefit with prior use of orthotics.  Custom orthotics have helped him avoid surgical intervention, but his orthoses had worn out.  As per the medical literature, custom orthotics are effective in the treatment of metatarsalgia. Therefore, the requested foot inserts (Foot, Insert, Removable, Molded to PT model, UCB Type, Berkley Shell  Code L3000) are considered medically necessary to treat the patient's condition.  Final Result: The reviewer determined that the service at issue is medically necessary for treatment of the patients condition. Credentials/Qualifications: The physician reviewer is board certified in Podiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a Synvisc One injection for treatment of her medical condition.  Findings: The physician reviewer found that the review of the submitted documentation and relevant literature demonstrates the medical necessity for the requested services. The evidence based literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. The study by Turajane and colleagues concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis which failed conservative treatment was found efficacious during a 54-month follow-up period. In this case, the patient has been diagnosed with right knee osteoarthritis. She has been treated with prior viscosupplementation injections with good pain reduction, followed by gradual return of symptoms. She has also failed to respond to other conservative treatment. Therefore, the requested Synvisc One injection for the right knee is medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested services are 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for a speech therapy evaluation for possible dyslexia. This patient is demonstrating some challenges with learning that could be related to ADHD or could be related to dyslexia. However, speech therapy is not the appropriate approach to identify whether she has dyslexia. Previous testing suggested significant problems with articulation and intelligibility. Therefore, the patient requires further cognitive and achievement testing which could be performed by the school or with a psychologist. Based on the previous testing, she does not need a speech and language evaluation to identify dyslexia. Thus, the requested speech therapy evaluation is not medically necessary for further evaluation of this patients medical condition. 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 reviewer is board certified in pediatrics with expertise in neurodevelopmental behavioral pediatrics 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 56-year-old female enrollee requested authorization and coverage of high-dose chemotherapy and autologous stem cell transplant. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees breast cancer.Three physician reviewers performed an experimental/investigational Independent Medical Review. All 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. Because all three physician reviewers concluded that the requested therapy is not likely to be more beneficial for 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for methadone HCL 10 mg, one tablet every four hours. The step-wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. There is no documentation of the completion of behavior therapy despite significant research to support its use. Furthermore, no objective treatment goals for pain and function are noted for the requested medications. The Centers for Disease Control and Prevention (CDC) also state that when opioids are started, providers should prescribe the lowest effective dosage. Finally, not all non-opioid and non-narcotic medications classes have been optimized or tried. For these reasons, the requested methadone HCL 10 mg, one tablet every four hours, is not medically necessary for treatment of the patients medical condition.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 sub-specialty certification in pain 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested continued skilled nursing facility level of care with resumption of physical therapy, occupational therapy, and speech therapy services for treatment of his medical condition.  Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for continued skilled nursing facility care has not been established. Functional impairments due to acquired brain insults such as stroke can improve with time, such as natural recovery processes, but are also amenable to rehabilitation interventions. The role of inpatient rehabilitative care for persons with significant functional deficits following stroke is relatively well-established in the medical literature. In this case, reconditioning and ongoing rehabilitative management can be provided in a less intensive rehabilitation setting, such as in the home with supervision to custodial level assistance and community-based rehabilitative services, or in a custodial level facility.  There is a lack of 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 in the available records. As such, continued skilled nursing facility level of care with resumption of physical therapy, occupational therapy, and speech therapy services was not and is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not and 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: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested ChemoFx Assay   for evaluation of her ovarian cancer.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the testing at issue in this patients case.  The medical records indicate a de novo presentation of stage IIIc ovarian cancer.  In this clinical setting, the standard of care is to offer optimal surgery followed by chemotherapy.  One of the first determinations to make in relapsed patients is whether the tumor is platinum sensitive or resistant, and the longer the treatment-free interval, the higher the probability of response to platinum chemotherapy.  The paclitaxel/platinum combination has proven to be superior over single agent platinum therapy in several clinical trials.  A thorough evaluation of these technologies was performed by the American Society of Clinical Oncology in 2004.  In their review of this technology, the panel concluded that such in vitro drug testing should be limited to clinical trials.  The current medical evidence does not support the testing at issue in this clinical setting.  All told, ChemoFx Assay provided on the said date was not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services for treatment of his behavioral health condition. Findings:  The physician reviewer found that residential treatment center services provided were not and are not medically necessary for treatment of the patients behavioral health condition. The patient had no post-acute withdrawals. There was no evidence of suicidality or homicidality, and he was medically and psychiatrically stable. There were no emotional, behavioral, cognitive, or impulsive symptoms that support the medical necessity of residential treatment level of care. He was not manic or psychotic. He was engaged in treatment.  His family has been supportive. The patient did not require the 24-hour a day environment of residential treatment and he could have been stepped down to a lower level of care. Final Result: The reviewer determined that the services at issue were not and 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 psychiatry with sub-specialty certification in addiction 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
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 56-year-old male with diabetes mellitus type 2.  He is presently well controlled on metformin, glyburide, pioglitazone (Actos), and exenatide (Byetta). According to the records, the patients hemoglobin A1c was 9.0% on metformin, a sulfonylurea, a thiazolidinedione and insulin.  He discontinued the sulfonylurea and the insulin and began taking Byetta.  As a result, his hemoglobin A1c dropped to 6.4%.  The patients request for authorization of Byetta was denied by the Health Plan based upon a determination that it was not medically necessary for treatment of his type 2 diabetes.Patients who are not well controlled on oral agents generally progress to insulin therapy.  Byetta is at least as effective as insulin in improving blood glucose control. Byetta is indicated as adjunctive therapy to improve glycemic control in patients who are taking metformin, a sulfonylurea, or both, but have not achieved adequate blood glucose control. As an added benefit, treatment with Byetta is associated with weight loss as opposed to insulin, where treatment frequently causes further weight gain.This patient was not well controlled on multiple medications as demonstrated by a hemoglobin A1c of 9%.  When Byetta was added to these agents, the patients blood glucose values dramatically improved and his hemoglobin A1c decreased to 6.4%.  The improvement in the patients blood glucose control demonstrates the medical necessity of Byetta in this case. Based upon the information set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.