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

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential mental health and substance for treatment of the enrollees behavior health condition.  Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The confluence of the patients multiple conditions, and their concerning totality of sequelae and subsequent functional impairment with potential for morbidity, warranted aggressive treatment in a supervised setting. Biologically, the patients seizure disorder, substance use, and treatment with multiple medications, some of which lower the seizure threshold while others fortify the barrier, introduced a particularly challenging element of complexity and risk for complications. Further, it is well-established that alcohol withdrawal is associated with the most serious risk for seizures in patients with epilepsy. Psychologically, it appears that the patient had struggled with developmental task of identity formation, which is not uncommon in context of a chronic medical illness, such as epilepsy, and would only be exaggerated, with the suicide of a parent.  It is more than likely that his history of irritability, and both self-defeating and self-medicating behaviors were steeped in psychodynamic therapy.  Socially, the patient was unable to control his substance use.  His longest period of sobriety had been two weeks. Even though he had not pursued an intermediate level of care for his drug use, such as partial hospitalization, according to the American Psychiatric Association, Residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. All told, the submitted documentation demonstrates the medically necessity of the residential mental health and substance use treatment program for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The representative of a deceased enrollee has requested reimbursement for the electric tumor field treatment (Optune) for treatment of the enrollees recurrent glioblastoma multiforme.  Findings: Two physician reviewers found that Electric tumor field therapy is considered the standard of care as both adjuvant therapy in combination with Temodar and for recurrent disease per the National Comprehensive Cancer Network (NCCN) guidelines. Electric tumor field therapy is U.S. Food and Drug Administration (FDA) approved based on a study showing better quality of life with use of alternating electric field therapy (Stupp, et al). Given the lack of treatment options for high grade gliomas and the efficacy and good tolerability of electric tumor field therapy, the treatment was likely to be superior to other treatment options. Therefore, the electric tumor field treatment (Optune) was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the services at issue were 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and hematology 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

A 25-year-old female enrollee requested authorization and coverage of partial hospitalization services. The Health Plan  denied the request indicating that the requested services are not necessary for treatment of the enrollees anorexia and 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 services are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 32-year-old female with chronic pain associated with myofascial pain, and nephrocalcinosis. She is status post C1 laminectomy and suboccipital craniectomy. The patient and her physician are requesting authorization for Actiq to help control the patients chronic pain. The Health Plan has denied the request on the basis that Actiq is not medically indicated for treatment of the patients chronic pain.Actiq is a short-acting narcotic with clearly limited indications. Actiq is approved for cancer related chronic pain syndromes refractory to the usual narcotic and other pain management techniques. There is no evidence suggesting the patient requires Actiq or that other indicated pain relief medications and therapies are ineffective or contraindicated for the patient. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 39-year-old female enrollee has requested Botox for treatment of her chronic migraine.  Findings:  Two physician reviewers found that the patients headache history meets criteria for chronic migraine. In addition, she has failed more than three standard therapies. Moreover, the records indicate the patient was treated with Botox recently and a note reported a significant decrease in headache days and headache intensity. Botox is FDA approved for patients with chronic migraine, and this patient meets all of these criteria. For these reasons, the requested Botox therapy is likely to provide this patient with an improved health outcome when compared with standard therapies.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested home care (private duty nursing) for treatment of the enrollees mitochondrial disorder.  Findings: The physician reviewer found that, upon review of the record, the submitted documentation fails to demonstrate the medical necessity for the requested services. Current treatment for patients with mitochondrial disease remains supportive. Issues that may require evaluation and intervention include respiratory failure, seizures, cardiomyopathy and conduction defects, ophthalmoplegia, neurologic deficits (including dysarthria, dysphagia, weakness, spasticity, and/or ataxia), and cognitive impairment. In this case, the patient appears stable without any acute concerns or recent complications. The documentation does not support that she has had any complications including infections, skin problems or recent injuries. The patient requires assistance with ADLs including bathing and toileting, but these tasks can be performed by a non-skilled person. The records show the patient is able to tolerate an oral diet but also receives liquid dietary supplements and medications via a feeding tube. Moreover, the documentation does not support that the patient requires any physical, speech or occupational therapy. She is at her baseline functional status. The patient has been stable without any recent illness or injury documented. The records do not show that the patient requires any skilled nursing needs and she does not require any complex wound care. The administration of nutrition and medications via a feeding tube and care for a tracheostomy can be performed by a non-skilled person. Therefore, in light of the submitted records, the requested services for treatment of this patients chronic medical condition are not medically necessary.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 magnetic resonance imaging (MRI) of the lumbar spine for treatment of her medical condition.  Findings: The physician reviewer found that in this particular patient, an MRI is not medically necessary for evaluation of the patients medical condition. Medical literature supports obtaining an MRI in anticipation of some sort of intervention such as surgery or facet injections. Prior to an intervention, standard medical practice is to attempt a trial of conservative treatments such as physical therapy, a targeted exercise program, or methodical use of anti-inflammatory drugs. The patient has had a relatively short duration of symptoms; lack of disc space narrowing on plain x-rays; and a lack of documented failure of conservative treatment.  As stated by Roudsari and Jarvik, `All of the guidelines emphasize the importance of a focused history and thorough physical examination before any imaging is ordered. In addition, all agree that for patients with acute LBP [low back pain] and without any risk factor for serious spine abnormalities, imaging within the initial 48 weeks should not be performed.`  Moreover, The American College of Radiology (ACR) has established appropriateness criteria for the evaluation of low back pain. The ACR agrees that MRI is not warranted in the acute setting. In the setting of low back pain in which the patient is a candidate for surgery or other intervention, then the ACR considers an MRI to be the most appropriate study, with no stipulation about delaying the MRI. Thus, a strong recommendation against the routine use of MRI for chronic low back pain (CLBP) evaluation is made. Chou and colleagues make the specific recommendation that, There is insufficient evidence to support the routine use of MRI in patients with CLBP.  For the reasons stated above, the medical necessity of the requested MRI has not been established.  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 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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication, brand name Lo Loestrin Fe. The enrollee has a history of menstrual cramps since the age of 12, and has been on birth control since then. She has tried a number of different birth control pills and reports they have caused abdominal cramps, nausea and weight gain.  A progress note describes an enrollee report that the generic version of Lo Loestrin Fe caused severe nausea, irregular menstruation and fatigue.  She reports that Lo Loestrin Fe is the only medication that has been effective for her. The enrollees obstetrics and gynecology doctor is requesting authorization of Lo Loestrin Fe. Literature reports many types of birth control are beneficial for the treatment of menstrual cramps; including combined oral birth control pills, the patch, ring, or implant, and an injection, among others.  This enrollee has tried the patch, the injection, and several oral birth control pills.  She has used two of the oral birth control pills on the formulary.  She has had side effects to all of them except for Lo Loestrin Fe.  Therefore, since she has tried and failed on of the formulary medications, and there are no generic versions of this medication, Lo Loestrin Fe is medically necessary.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in obstetrics and gynecology and reproductive endocrinology 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 authorization and coverage for ultraviolet light therapy. The submitted documentation supports the medical necessity of the requested services. She has tried and failed therapy with topical steroids, calcipotriene and Otezla. The medical records indicate that her psoriasis is moderate to severe in severity and includes some guttate lesions. This makes it difficult to use topical therapies alone as treatment, given the widespread areas on which to apply the medication. The use of ultraviolet light therapy to help widespread psoriasis has been well-established and is often required as a prerequisite treatment before systemic treatments are approved. The medical evidence supports the requested services in this clinical setting. Therefore, the requested ultraviolet light therapy is medically necessary for the treatment of this patient.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 reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Imvexxy vaginal insert 4 mcg. The U.S. Food and Drug Administration (FDA) approves the use Imvexxy, a vaginal estradiol insert,  for the treatment of moderate to severe dyspareunia, a symptom of vulvar and vaginal atrophy, due to menopause. Archer and colleagues report that vaginal estradiol softgel capsules result in negligible to very low systemic absorption of estradiol and provide local benefits with limited systemic exposure. In this case, the records document that the risk/benefit profile regarding systemic absorption of estrogen in the setting of this patients breast cancer history was discussed with an oncologist. Given that the one of the vaginal estrogen preparations with the lowest systemic absorption is a standard regimen of the 4 mcg estradiol tablets such as Imvexxy, the requested medication is medically indicated. Therefore, Imvexxy vaginal insert 4 mcg is 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 obstetrics and gynecology 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 physical therapy services at a frequency of three times per week for six months and occupational therapy services at a frequency of three times per week for six months. Spinal cord compression (e.g., due to spinal stenosis) can result in functional impairments in various domains, such as self-care, mobility tasks, bladder function and bowel function. These impairments may persist despite surgical decompression. These impairments require individualized rehabilitative measures and supportive care to address and manage. In this case, the patient underwent surgical decompression of multilevel cervical stenosis and was transferred to a skilled nursing facility for further care. Postoperatively, he has had profound functional impairments. He has been undergoing rehabilitation since early January 2019, but has continued to remain essentially dependent for all care and mobility. Limb strength has remained at the poor to poor plus level. He has remained non-ambulatory. The requested skilled therapy services are not medically necessary at this time given that they are not expected to positively impact the patients clinical or functional course or outcomes beyond a basic maintenance/restorative program. Resuming formal therapies can be reconsidered if there is significant neurological recovery in the future, which would provide a substrate with which the therapists could work. Therefore, physical therapy services at a frequency of three times per week for six months and occupational therapy services at a frequency of three times per week for six months are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: An enrollee has requested authorization and coverage for an increase of Korlym 300 mg to a quantity of 150 for the duration of 30 days for treatment of the enrollees Cushings syndrome. Findings:  The physician reviewer found that Cushings syndrome, a collection of signs and symptoms due to prolonged exposure to cortisol, is associated with poor quality of life and morbidity.  While optimum treatment typically consists of selective and complete resection of the causative tumor, the development of new drugs offers clinicians several choices to treat patients with residual cortisol excess following the surgery. The U.S. Food and Drug Administration (FDA) has recently approved the antiprogestin Korlym (mifepristone) for control of hyperglycemia secondary to hypercortisolism in adults with endogenous Cushings syndrome who have type 2 diabetes/glucose intolerance and have not responded to, or are not candidates for, surgery. Multiple case reports and small series have suggested that mifepristone administration leads to clinical improvement in the majority of Cushings syndrome patients and does not pose the risk of hepatotoxicity, a rare but potentially serious side effect of ketoconazole.  This patient has responded well to Korlym. The medical evidence supports the requested medication quantity in this clinical setting. Therefore, an increase of Korlym 300 mg to a quantity of 150 for the duration of 30 days is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication quantity 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 endocrinology, diabetes and metabolism 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 66-year-old male enrollee has requested Bystolic for the treatment of his hypertension. Findings:  The physician reviewer found that although there are fewer side effects associated with this drug, there is no indication for Bystolic to be selected over any of the other beta-blockers.  The Health Plans position that the patient try a third beta blocker in addition to Coreg and atenolol before being given Bystolic is medically reasonable and appropriate.
Appeal type: Urgent Care
Decision: Upheld

A 43-year-old male enrollee has requested urgent care services for treatment of his medical condition. Findings:  The physician reviewer found that the issue in this case is whether a prudent person in the patients circumstances would believe he or she was experiencing an urgent medical condition requiring immediate medical services. Urgently needed services are defined as services necessary to prevent serious deterioration of the health of a patient, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the patient returns to the plans service area. This case does not meet the prudent layperson criteria for urgent care. The urgent care notes document only one complaint reported by the patient, dry throat following an upper respiratory infection. The records do not document any severe symptoms that would indicate to a prudent layperson that his health or bodily functions were at risk of serious deterioration. At the time of presentation, the patient had throat discomfort which is common and is not a condition for which most laypersons seek urgent care. The patient did not present with symptoms concerning for H1N1 and no documentation of fears about H1N1 were noted in the urgent care records. All told, the evidence provided does not demonstrate that the patient was experiencing symptoms such that a prudent layperson in his situation would believe he was at risk of serious deterioration if he did not seek urgent treatment. As such, this patients condition did not require urgent care at the time the services at issue were provided.