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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Ambien CR for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Ambien has been approved for short-term treatment of insomnia (with difficulty of sleep onset), and Ambien CR has been approved for the long-term treatment of patients with insomnia manifesting as both difficulty with initiation and maintenance of sleep.  When treating insomnia, all patients should receive therapy for any medical condition, psychiatric illness, substance abuse, or sleep disorder that may be precipitating or exacerbating the insomnia.  For patients who continue to have insomnia that is severe enough to require intervention, cognitive behavioral therapy (CBT) is the initial therapy that is recommended.  If a patient requires a combination of behavioral therapy and medication, a short acting medication is recommended for six to eight weeks and then tapered.  If symptoms continue, an evaluation in a sleep disorder center prior to the institution of long-term medications may be appropriate.  In this case, the documentation does not support that the patient has received optimal non-pharmacologic treatment for insomnia that may include CBT or an evaluation by a sleep specialist.  There is a lack of support for the requested medication in this clinical setting.  All told, Ambien CR is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  The reviewer is board certified in internal 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

The parent of a three-year-old male enrollee has requested  for continued intensive, in-home, one-on-one, ABA therapy for treatment of the enrollees autism. Findings:  Two physician reviewers found that the evidence for the effectiveness of ABA therapy with autism is extensive, and it is considered standard of care and the treatment of choice. Interventions must be intensive and should be started at an early age by trained professionals. The US Surgeon General supports ABA therapy as the recommended form of treatment for autism. It has been shown to be efficacious with several studies demonstrating sustained improvement in areas of functioning, including social and communication skills.
Appeal type: Experimental/Investigational
Decision: Upheld

A 43-year-old male enrollee requested authorization and coverage of an interferential current stimulator for the treatment of chronic back pain.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old male enrollee has requested positron emission tomography/computerized tomography (PET/CT) scan for evaluation of his Hodgkins lymphoma.  Findings:  The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines place this patient at high risk for recurrence due to prior two recurrences. However, there is no clinical or biochemical marker to suggest recurrence at this time. In addition, the records indicate that the patients last two PET scans have been negative. While PET/CT is easier to interpret than conventional CT due to the physiologic capacity of PET, the literature does not support the use of PET for routine surveillance without clinical evidence to suggest recurrence. The guidelines recommend routine CT surveillance every six months for two years and then re-evaluation for a plan of surveillance in an asymptomatic patient. Thus, the requested PET/CT scan is not supported as medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Rexulti 0.25 mg (30) with 12 refills. This patient presents with a history of bipolar disorder, current episode depressed. The records reviewed document that the patient has been treated with Abilify and three other atypical antipsychotics without adequate symptomatic improvement. Moreover, the patient experienced severe side effects with each of the attempted atypical antipsychotics. The patients provider has recommended treatment with Rexulti. The patient is responding to Rexulti, which is less likely to cause EPS than aripiprazole (Stahl). According to Citrome and colleagues, clinical trials of Rexulti have demonstrated its efficacy for use as an antidepressant in patients demonstrating inadequate responses to psychopharmacology management. Given these findings, the requested Rexulti 0.25 mg (30) with 12 refills is medically necessary for 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 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 23-year-old female with previously diagnosed bulimia nervosa since age 12, with a past history of binging and purging at least once a day. The patient was previously treated on an inpatient basis for about 30 days, felt to have improved, but having suffered some relapse. As of her discharge from that inpatient stay, the patient had been in treatment with a nurse practitioner, seeing her once a month for medication treatment, as well as a therapist who was seen once to twice per week. Because of the level of relapse she had, the patient was referred for residential treatment by both her nurse practitioner and her therapist. The patient identified her ideal weight as 125 pounds and at admission, weighed 123.2 pounds, was normotensive, and devoid of lanugo hair though with multiple dental fillings as well as some cavities. Admission labs were unremarkable. Psychiatric evaluation noted the patient as coming to the interview willingly and is cooperative. She relates her story in a concise, logical manner. Somewhat thin but not excessively cachectic. Facial expression is happy, eye contact is good. Manner of relating to the interviewer was friendly, trustful, and actively cooperative. She is motivated for treatment. During her residential stay, her Celexa 80mg was continued and Effexor was added. Though this patient had suffered from bulimia nervosa, it does not appear that she was nearly as encumbered with it as she had been in the past, such that she needed something as intensive as residential treatment. Whether from standpoints of admission weight, labs or her mental status exam, there really appears to be a lack of evidence pointing to even a need for an inpatient program. Given that the patient was only seeing a nurse practitioner once a month prior, there could have been a number of other modalities instituted other than residential treatment, which could have been as or more effective. In addition, if the patients condition was at such a level that residential treatment was required, it is unclear why a psychiatrist was not involved in her treatment. Given the patients history and condition at the time of admission, intensive outpatient services or partial hospitalization would have been appropriate treatment considerations. The evidence does not support the need for residential treatment. Therefore, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a three-year-old male enrollee has requested applied behavioral analysis (ABA) therapy services for treatment of the enrollees receptive-expressive language disorder and pervasive developmental disorder. Findings:  The physician reviewer found that the submitted documentation does not include conclusive testing establishing a diagnosis of autism spectrum disorder. Psychometric testing at age two years and four months noted a full-scale IQ of 106 and a later study at three years and eight months noted a full-scale IQ of 82 (low normal). Although autistic children can have normal full-scale IQs, especially those with Aspergers syndrome, it is unusual for children diagnosed with pervasive developmental disorder  not otherwise specified (PDD-NOS) to have a normal IQ. A study by Zander and colleagues noted that in 520 children with PDD-NOS the average IQ was -2 standard deviations below average. Additionally, the in-plan evaluation performed in August 2012 found that the patient did not meet the diagnostic criteria for autism. Although the psychological evaluation in February 2013 noted a provisional diagnosis of PDD-NOS, this evaluation did not include direct testing or observations by the psychologist other than the IQ testing. Based upon the documentation provided, there is inadequate confirmatory evidence that the patient has an autism spectrum disorder.  As such, the medical necessity of ABA therapy has not been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the human papilloma virus (HPV) vaccine, Gardasil 9. The current medical evidence does not support the requested services in this clinical setting. The patient has a history of HIV and recent low CD4 counts. The Centers for Disease Control (CDC) currently recommends the HPV vaccine series to protect against human papillomavirus for men and women who are 26 years of age or younger. There are studies that demonstrate the efficacy and safety of this vaccination in patients with HIV. Most of the studies are in women. Researchers evaluated the safety and immunogenicity of the quadrivalent HPV vaccine in men who were HIV positive. Of note, this was a small study of only 162 patients, and the authors recommended further studies. In sum, there is a lack of support for the HPV vaccine in men with HIV who are older than 26 years of age. Although the U.S. Food and Drug Administration (FDA) has recently approved this vaccine for use in older individuals, there is a lack of guidelines to recommend its use. There is a paucity of literature supporting the use of the HPV vaccine in males who are HIV positive and older than 26 years of age. Therefore, the HPV vaccine, Gardasil 9, is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal 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 a motorized wheelchair for treatment of his low back pain. The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested motorized wheelchair. According to the documentation submitted for review, the patient does not have impairments that would preclude the use of a walker for accomplishing his basic mobility-related activities of daily living. The physical examination noted that the patient was ambulating with a walker. He has some weakness at the left lower limb that could be addressed with an orthosis. The orthosis that he has can be adjusted for better fit if there is pain at the lateral foot. In addition, more prolonged mobility-related needs could be addressed with a manual wheelchair. He does not have documented impairments that would preclude the use of an appropriately fitted manual wheelchair. Poor tolerance and endurance with manual wheelchair mobility can be addressed with strengthening and conditioning, not by avoiding physical activity. Finally, the patient does not live in a residence that is accessible to a power mobility device. Based on the clinical documentation submitted, a motorized wheelchair is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested equipment is 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 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: Overturned

Nature of Statutory Criteria/Case Summary: A 54-year-old male enrollee has requested reimbursement for a carotid duplex scan of extracranial arteries with complete bilateral study for evaluation of the enrollees carotid bruit. Findings:  The physician reviewer found that There is support in the medical literature for the services at issue in this clinical setting. In an effort to reduce the incidence of stroke, there has been extensive research into the most efficacious means to evaluate susceptible patients. As written in Rutherfords Vascular Surgery textbook, Results from two separate guidelines endorsed by the Society for Vascular Surgery support the use of DUS [duplex ultrasound] as the initial imaging modality for both asymptomatic and symptomatic patients. Initial carotid evaluation with DUS is acceptable for patients with a carotid bruit and to observe known asymptomatic stenosis. In addition, the American College of Radiology (ACR) has also established guidelines for cerebrovascular disease for a variant of asymptomatic patients who have a bruit discovered on physical examination. For these patients, the ACR considers a carotid duplex study to be the most efficacious procedure. Similarly, the American Institute for Ultrasound in Medicine and the American College of Cardiology have developed appropriate indications for carotid duplex ultrasonography. These guidelines support the use of carotid duplex ultrasonography as an appropriate first-line study for patients with an asymptomatic bruit. The medical literature as well as in standard practice, recommends evaluation of a bruit before the patient develops symptoms. Therefore, the carotid duplex scan of extracranial arteries with complete bilateral study was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for evaluation 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: Overturned

A 44-year-old male enrollee has requested for FES bike therapy for treatment of his spinal cord injury with paraplegia. Findings:  The physician reviewer found that the FES bike has been shown to reduce spasticity, prevent atrophy, improve cardiovascular conditioning and perhaps stimulate some neurological recovery
Appeal type: Experimental/Investigational
Decision: Overturned

A 54-year-old female has requested Botox injections for treatment of migraine headaches.  Findings:  Two physician reviewers found that the results achieved with Botox are variable, but there is considerable data suggesting its efficacy as a migraine preventive, especially when the frequency of attacks is high (chronic migraine). The patients headaches are refractory to standard preventives and there is a likelihood of success with Botox therapy. If not completely effective, Botox may still reduce the intensity and the frequency of the patients headaches.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old female enrollee has requested a reduction mammaplasty for treatment of her cervical neck and back pain. Findings:  The physician reviewer found that in the medical literature, Winn and colleagues commented that, The weight of reduction necessary to relieve the symptoms of symptomatic macromastia is probably the most controversial of the current criteria. In attempting to assess whether the amount of resection directly correlates with improvement in symptoms, conclusions from Freire and colleagues states that, We did not observe direct correlations between larger amounts of tissue excised and improvement in the pain intensity and functional capacity. Overall, Winn and colleagues concluded that, above 205 grams per breast, the weight of reduction is independent of symptom relief for patients with symptomatic macromastia. Given that this patients complaints, physical exam and plan for surgery are consistent with the standard of care as supported by multiple specialists as documented in the patients medical chart, the requested procedure has been shown to be reconstructive in nature and medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oxycodone-acetaminophen (Percocet) 10 mg/325 mg. The Centers for Disease Control and Prevention (CDC) guidelines state that, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. Per the CDC guidelines, Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. In this case, the patient has a history of liver cirrhosis, esophageal cancer, and back pain. The patient has been treated with Percocet for chronic pain related to her previous cancer pain and chronic lower back pain. The records document that the patient has undergone testing with multiple urine drug screens, which detected the presence of alcohol metabolites. On 1/25/22, the provider charted that chronic opioid therapy is not indicated when considering the risk-to-benefit ratio for Percocet was no longer favorable. The provider also expressed concern over the patients cirrhosis and the potential harm caused by the acetaminophen in Percocet. Given these findings, the requested oxycodone-acetaminophen (Percocet) 10 mg/325 mg is 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 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

An enrollee has requested authorization and coverage for intravenous (IV) lidocaine. Researchers found that IV lidocaine is effective and reasonably safe for the patients with proper monitoring and precautions, and the central anti-nociceptive and anti-hyperalgesic effects may allow for a wean from offending overused medications. In this case, the patient has debilitating chronic intractable migraines and chronic daily headaches refractory to multiple abortive and preventive medications and interventions. In retrospective studies, IV lidocaine can result in improvement of chronic daily headaches and withdrawal of analgesic medication. Given this support, the requested IV lidocaine infusions are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found requested IV lidocaine infusions are 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 medication 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 neurology 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: Overturned

The parent of a two-year-old female enrollee has requested speech and language therapy, physical therapy and occupational therapy for treatment of the enrollees Soto syndrome and global developmental delay.  Findings:  The physician reviewer found that Sotos syndrome is a medical genetic disorder characterized by a distinctive facial appearance, overgrowth in childhood, and learning disabilities or delayed development. People with Sotos syndrome often have intellectual impairment and most also have behavioral problems. Frequent behavioral issues include attention deficit hyperactivity disorder (ADHD), phobias, obsessions and compulsions, tantrums, and impulsive behaviors. It has been suggested that young patients with Sotos syndrome have particular difficulties with speech and language, particularly expressive language and articulation. Affected patients often have problems with sound production, stuttering, and a monotone voice. Additionally, weak muscle tone (hypotonia) may delay other aspects of early development, particularly motor skills such as sitting and crawling.  Overall, this patients records support a diagnosis of Sotos syndrome, with speech and language disorder and deficiencies in gross and fine motor skills. Consistent with the standards of practice for this patients medical condition, the requested physical therapy, occupational therapy and speech and language therapy are medically indicated and appropriate in this clinical setting.