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

A 43-year-old male enrollee requested acute hospitalization care or skilled nursing facility level of care for medical treatment of his traumatic brain injury.  Findings:  The physician reviewer found that the medical records document a catastrophic traumatic brain injury.  In the past, the patient has received extensive rehabilitation services.  More recently, the patient has been assessed and viewed to have had a plateau in his response to rehabilitation therapy.  In this clinical setting, skilled nursing facility level of care was and is medically appropriate.  There is sufficient support for skilled nursing facility level of care in this clinical setting.  However,  acute hospitalization care was not and is not medically indicated.  Thus, the medical records demonstrate the medical necessity of skilled nursing facility level of care.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 36-year-old male with diabetes mellitus type II, who is obese, insulin resistant and dyslipidemic.  He appears to have been untreated from 2000 until July of 2005. In July 2005 the patient started on Actos tablets and Lantus insulin with initial improvement in his hemoglobin A1c from 12.2% to 11.5%.  By September 2005 his A1c dropped to 9.1%.  The patient was also noted to have postprandial blood sugars in the 180 mg range; significantly above the American Association Of Clinical Endocrinologists recommendation of 140 mg. Byetta injections of 5 mcg twice a day were added to his diabetic regimen by his endocrinologist. Within six weeks the patient reported fasting blood sugars of less than 100 mg and postprandial levels around 120-30 mg. Because the Health Plan denied further authorization for the prescribed Byetta, the patients endocrinologist provided additional samples.  The patient has requested authorization for the prescribed medication but his request was denied by the Health Plan based on a determination that Byetta was not medically necessary for treatment of his type II diabetes.The patient is insulin resistant, requiring as much as 100 units of Lantus insulin to achieve basal control and he is also obese. He has had an excellent early response to Byetta at the starting dose of 5 mcg twice per day and would be expected to have an even better response with the full maintenance dose of 10 mcg twice per day.  The Health Plan did not recommend an alternative to the Byetta that would achieve the same level of improvement without causing substantial weight gain, which is a contraindication in diabetes mellitus type II.Although the FDA has not approved Byetta for use with Actos and/or Lantus insulin (or insulin of any type for that matter), available data demonstrates the likely effectiveness of Byetta when used in combination with Actos. Additionally, the response demonstrated by the patient supports the theory that the combination of basal insulin and Byetta is an ideal treatment program for patients with diabetes mellitus type II.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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for implantation of a Watchman left atrial appendage closure (CPT 33340) device, including a one-day inpatient hospital stay. In the PREVAIL trial, Holmes and colleagues reported that left atrial appendage occlusion was noninferior to warfarin for stroke prevention. In a meta-analysis report of left atrial appendage closure (LAAC) versus systemic therapy with warfarin for prevention of stroke, systemic embolism, and cardiovascular death, Holmes and colleagues reported that LAAC resulted in improved rates of hemorrhagic stroke, cardiovascular/unexplained death, and nonprocedural bleeding compared to warfarin. In this case, given the patients recurrent gastrointestinal bleeding, the requested service is likely to be more beneficial when compared to no anticoagulation or reinitiating long-term anticoagulation. Therefore, implantation of a Watchman left atrial appendage closure (CPT 33340) device, including a one-day inpatient hospital stay is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings: Three of the three physician reviewers found the requested implantation of a Watchman left atrial appendage closure (CPT 33340) device, including a one-day inpatient hospital stay 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 service is 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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Experimental/Investigational
Decision: Upheld

The parent of a 3-year, 5-month-old male enrollee has requested intravenous immunoglobulin (IVIG) for treatment of the enrollees pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).  Findings:  Three physician reviewers found that a review of the records provided for this patient reveals features of autism and a diagnosis of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). His provider is considering use of intravenous immunoglobulin (IVIG) for treatment of PANDAS based upon a comprehensive microbiological/neuroimmunological (in particular a high titer of anti-neuronal antibodies) and nutritional laboratory analyses. The association of streptococcal infection with basal ganglia disease, in particular, obsessive compulsive disorder and movement disorders such as Tourettes syndrome, remains controversial and the clinical data does not support a cause-and-effect for diagnoses such as PANDAS without additionally, substantially larger and carefully controlled clinical studies. From a historical perspective, a similar error was made for other entities, including Kawasakis disease. This makes treatment with IVIG for obsessive compulsive disorder (OCD) difficult to sanction, given that this condition may be a chronic condition, and the efficacy and safety of long-term IVIG therapy may be problematic. While neuroimmune abnormalities may be present in children that carry a diagnosis of tic disorder, OCD and history of streptococcal infections, systematic studies offer no supportive evidence for neuroimmunologic dysregulation secondary to streptococcal infection. Thus, IVIG treatment is unwarranted in non-specifically correcting an underlying immunologic defect that might give rise to these conditions and it should be considered investigational in this circumstance.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a manual wheelchair for treatment of the enrollee, who has a history of severely short stature. Findings:  The physician reviewer found that the records forwarded for review do not support the medical necessity for the requested equipment. The patient has multiple impairments precluding functional ambulation and functional propulsion of a manual wheelchair, including short limbs and brachydactyly. The patient uses a power wheelchair for independent mobility. A formal mobility assessment, which is an appropriate evaluation in this situation, verified this mobility status.  A manual wheelchair that the patient is not able to self-propel is not medically necessary, even if used as a backup.  She would be dependent on others for mobility.  The standard of care would be to arrange transportation that is capable of transporting her in her usual mobility device so that she can be independent after she arrives at her destination.  If her power wheelchair is inoperable, her mobility device vendor should supply her with an appropriate backup wheelchair for maintaining her independent mobility (i.e., a replacement power wheelchair) while her wheelchair is being serviced.  A plan and training of caregiver(s) should be in place to effectuate egress from the home in the event of an emergency should the power wheelchairs power functions be inoperable. Therefore, the requested manual wheelchair is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for Botox treatments provided from 6/16/16 forward. The Health Plan has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees migraine headaches. Findings:  The physician reviewers found that Botox is an effective, safe, and well-tolerated treatment for the prevention of headache for patients with chronic migraine. The medical records provided for review document failure of at least two prophylactic medications for migraine. The patient is having chronic headaches, migraine type, and does specifically delineate and quantity the frequency of the headaches in terms of days per month on an ongoing basis with headaches lasting at least four or more hours on 15 days or more per month for at least three months. Further, treatment with Botox has been effective in reducing the patients headache frequency and severity with positive functional benefit. All told, Botox treatments were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the services at issue were and 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 reviewers number one, two, and three are board certified in neurology and 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lorzone 375 mg tablets. Chlorzoxazone (Lorzone) is a muscle relaxant that works primarily in the spinal cord and the subcortical areas of the brain. The mechanism of action is unknown but the effect is thought to be due to general depression of the central nervous system. Advantages over other muscle relaxants include reduced sedation and less evidence for abuse. Muscle relaxants usually cause drowsiness and dizziness but chlorzoxazone is better tolerated. However, chlorzoxazone should be avoided if the patient has a history of liver disease.  Muscle relaxants are prescribed for a variety of indications, however the comparative efficacy of these drugs is not well known. Skeletal muscle relaxants consist of both antispasticity and antispasmodic agents. The efficacy data from comparator trials do not particularly favor one skeletal muscle relaxant over another. Therefore, the choice of a skeletal muscle relaxant should be based on its adverse-effect profile, tolerability, and cost. Chlorzoxazone is particularly well tolerated according to current literature. As such, after unsuccessful use of cyclobenzaprine, the prescription of chlorzoxazone is appropriate, reasonable, and medically necessary. Therefore, Lorzone 375 mg tablets are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for partial hospitalization services received on the basis that the services at issue were emergent in nature. Findings:  The physician reviewer found during their review of the submitted documentation that the patient was experiencing a psychiatric emergency upon admission to PHP. However, the records demonstrate the patient subsequently improved with treatment and was no longer experiencing a psychiatric emergency. The psychiatrist reported that the patient was improving. He denied any suicidal or homicidal ideation. Although the patient remained anxious and sad, he was cooperative and did not have psychosis. The patient was no longer at imminent harm to himself or others. He was not gravely disabled. The patient had stabilized to the point that he was able to attend to activities of daily living. While the patient continued to require treatment for his major depressive disorder with psychotic features, he had experienced sufficient improvement to be discharged from his current facility. Therefore, the services at issue were not necessary for treatment of a psychiatric emergency medical condition. Final Result: The reviewer determined the patient did not receive psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. 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: Overturned

A 51-year-old female enrollee has requested authorization and coverage for continued inpatient psychiatric treatment (psychiatric acute inpatient care) and inpatient electroconvulsive therapy for treatment of the enrollees major depressive disorder, severe, recurrent, without psychotic features.   Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  This patient is severely depressed, with multiple risk factors.  Mood disorder, such as depression, is the psychiatric diagnosis most commonly associated with suicide.  Electroconvulsive therapy is the most effective intervention for severe mood disorders.  Inpatient psychiatric care is aimed at decompressing the acute exacerbations of episodic serious mental illness.  The current medical evidence supports continued inpatient psychiatric treatment in this patients case.  The requested services are appropriate to treat this high-risk patient and are consistent with standards of good medical practice.  All told, continued inpatient psychiatric treatment (psychiatric acute inpatient care) and inpatient electroconvulsive therapy are medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for infusions of Privigen.Researchers conducted a study to assess the impact of treatment with intravenous human immunoglobulin (IVIG) on the outcome of BK virus-associated nephropathy (BKVN) in renal transplant recipients. BKVN can cause clinically significant viral infection in renal transplant recipients, leading to allograft dysfunction and loss. Vu and colleagues found that IVIG administration appeared to be safe and effective in treating BKV viremia and BKVN and preventing graft loss in patients who had inadequate response to immunosuppression reduction and leflunomide therapy. In this case, the patient has elevated BK viremia in the setting of a renal transplant, and immunosuppression has been reduced with persistent viremia. In addition, cidofovir would have concerns with regards to renal toxicity. IVIG has been shown to improve graft survival under these circumstances and has been shown to be safe. Accordingly, the requested infusions of Privigen are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in infectious 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

The patient is a 67-year-old female who is status post keratoplasty in the left eye with a refractive error of + 3.00  7.00 x 59 degrees with visual acuity of 20/100 in the left eye. The submitted notes from her ophthalmologist show no improvement in visual acuity with a pinhole. The patients ophthalmologist has recommended the patient undergo photorefractive keratectomy of the left eye. The Health Plan has denied authorization for this procedure on the basis that it is not medically necessary for treatment of the patients condition.The patient wishes to undergo photorefractive keratectomy in her left eye that has 8.5D of corneal astigmatism following penetrating keratoplasty. While this may be an appropriate treatment in an eye with better potential vision, the refraction in this patient demonstrates a best-corrected vision in the left eye of only 20/100. Thus, based on the limited degree of potential visual improvement in this patient, photorefractive keratectomy is not medically warranted.Accordingly, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 38-year-old male enrollee has requested use of a dynamic adjustable ankle extension/flexion device (Dynasplint) for the treatment of his ankle joint contracture/fasciitis. Findings:  Two physician reviewers found that the submitted documentation in this case indicates that a dynamic orthosis (Dynasplint) has been requested for the condition of plantar fasciitis. Limited clinical information is contained in the records submitted by the patients provider. Specific details regarding previously failed standard therapies are not documented. A review of the medical literature indicates that there have been very few published studies regarding the use of the Dynasplint device for plantar fasciitis. Those studies which have been performed are small and non-controlled and are only preliminary studies. Thus, the efficacy of the Dynasplint device for the treatment of plantar fasciitis remains unproven at this time. Furthermore, the submitted clinical evidence does not demonstrate that standard proven therapies have been exhausted in this particular case.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 53-year-old man with a long-standing history of knee pain. The patients symptoms persist and he wishes to undergo further surgery. The patient has seen several orthopedics for his condition. He has requested authorization for another orthopedic consultation. The Health Plan has denied the request on the basis that the requested consultation is not medically necessary.The Health Plans denial should be upheld. There is no evidence another orthopedic consultation is medically indicated. Upon review of the patients history and the submitted records, it appears the patient has received appropriate care for his condition. There is no evidence that removal of the Bakers cyst is medically necessary or is likely to resolve the patients pain. It appears the patient will eventually require knee replacement surgery. In addition, a weight loss program is indicated. At this time, there is no medical justification for another orthopedic consultation. Therefore, I have determined that the requested consultation is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential mental health treatment services.  The submitted records fail to demonstrate the medical necessity of the services at issue. Although still ill and in need of comprehensive care delivered in accordance with a multidisciplinary treatment plan, the clinical note described a calm patient with reasonable insight. She was having mild ideas of reference and delusional thinking, but her thought processing was linear and organized. She was not gravely disabled. Her mood was good. She did not have any suicidal ideations or homicidal thoughts. There was no mention of aggressive or disruptive behavior, or an inability to attend to her activities of daily living. She was clean and sober, and taking her psychotropic medications, including a new antipsychotic that helped reduce her paranoia.  She did not have medical issues that would warrant service delivery at the residential level of care. The records indicate that the patient had quickly reconstituted from a brief exacerbation of symptoms in context of chronic mental illness and possible medication non-adherence.  There was no evidence that partial hospitalization in a supportive living environment would have been unsafe or inadequate at the time. Thus, residential mental health treatment services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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.