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

The patient has requested authorization and coverage for trigger point injection, occipital nerve block injection, and peripheral nerve block injection. The American Headache Society noted that there is a paucity of evidence from controlled studies for the use of peripheral nerve blocks in the treatment of primary and secondary headache disorders, with the exception of greater occipital nerve blockade for cluster headaches. The consensus guidelines did not find evidence to support using occipital nerve blocks and trigger point injections for occipital neuralgia as the best evidence is for cluster headaches. Researchers found limited data on the efficacy of peripheral nerve blocks and trigger point injections for the treatment of headache syndromes. Regarding the treatment of other headaches and cranial neuralgias, controlled studies are still necessary to clarify the real role of peripheral nerve block.In this case, the patient has been diagnosed with occipital neuralgia and myalgias related to a motor vehicle accident. An MRI of the brain revealed findings suggestive of a remote shearing injury consistent with whiplash. She is actively participating in occupational therapy and has undergone occipital nerve blocks and trigger point injections with an unquantified level of pain relief lasting for one week before her symptoms returned. There is a lack of documentation of significant efficacy or duration to warrant repeating the procedure when weighed against the risks of overexposure to steroids found in the injection material. Based on the available medical records for review and current guidelines, the requested trigger point injection, occipital nerve block injection, and peripheral nerve block injections are not medically necessary for 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 anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the computed tomography (CT) perfusion with contrast. Findings:  The physician reviewer found that the acute management of strokes has undergone a fundamental change in the last several years. Typically, a patient presents with stroke symptoms, and a decision must quickly be made regarding whether thrombolytic therapy is indicated. This might include venous administration of tissue plasminogen activator (tPA), intra-arterial administration of tPA, or even surgical/radiologic thrombectomy. However, there is an upper time limit in which tPA is most effective. Thus, a provider must distinguish whether the suspected stroke is ischemic or hemorrhagic. This is generally easily accomplished with a simple unenhanced CT scan of the brain. In an ischemic stroke, the next step is to determine which patients will likely benefit from aggressive therapy. Performance of a perfusion MRI study can help determine the presence of salvageable brain tissue. In the medical literature, it is noted that our analyses provide support for the hypothesis that perfusion computed tomography improves the identification of patients likely to respond to thrombolysis, and also those in whom natural history may be difficult to modify with treatment. Further, the American College of Radiology (ACR) reported that use of perfusion CT may be appropriate when stroke is considered. In this particular patient, the MRI was not conclusive, and a perfusion CT perfusion study was a reasonable alternative. For these reasons, the CT perfusion with contrast was likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three physician reviewers found the CT perfusion with contrast was likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the CT perfusion with contrast was likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in diagnostic radiology and are actively practicing. Physician reviewer2 is board certified in radiology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Tepezza (teprotumumab) 500 mg.According to Hiromatsu and colleagues, Graves ophthalmopathy is an autoimmune disorder of the orbit that is clinically relevant in 25-50% of patients with Graves disease. Complications of Graves ophthalmopathy include inflammation, proptosis, and/or diplopia. Glucocorticoid therapy, which has been the mainstay of treatment for Graves ophthalmopathy, has had limited efficacy and presents safety concerns. Teprotumumab is a novel therapy for treatment of patients with active, moderate-to-severe Graves ophthalmopathy. Smith and colleagues state that teprotumumab has a favorable safety profile and has demonstrated remarkable effectiveness in moderate to severe, active Graves ophthalmopathy. In this case, the patient has been diagnosed with Graves ophthalmopathy (thyroid eye disease). Notes indicate that the Graves ophthalmopathy is active and manifests as irritation, lacrimation and diplopia. The medical evidence supports the requested medication in this clinical setting. Therefore, Tepezza (Teprotumumab) 500 mg is medically necessary for the treatment of the patients medical condition.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 internal medicine with subspecialty 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a magnetic resonance imaging (MRI) of the abdomen (pancreas) for evaluation of his medical condition.  Findings:  The physician reviewer found that in the peer-reviewed medical literature, Del Chiaro and colleagues reported that while some cystic lesions of the pancreas show benign behaviour (serous cystic neoplasm), others have an unequivocal malignant potential (mucinous cystic neoplasm, branch- and main duct intraductal papillary mucinous neoplasm and solid pseudo-papillary neoplasm). Schmid and Siveke found that in most cases, cystic lesions are detected incidentally by computed tomography and magnetic resonance imaging (MRI) performed for other reasons. Thus, the literature seems to support the use of CT or MRI for pancreatic imaging for mass. This patients follow-up CT showed no pancreatic mass, thus the requested MRI is not medically necessary for further evaluation of this patients medical condition.  Final Result: The reviewer determined that the requested diagnostic procedure 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 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: Upheld

A 35-year-old female enrollee has requested a power-operated vehicle (POV) for mobility. Findings:  The physician reviewer found that there is no specific evaluation of the patients upper body strength, range of motion or her ability to propel a manual wheelchair. There is no indication the POV is needed for activities of daily living (ADLs) within the home.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that the physician reviewer found According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1 patients should be treated with Harvoni for 12 weeks or Zepatier for 12 weeks, and the medications are U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 infection regardless of fibrosis stage. The guidelines recommend either Harvoni or Zepatier as acceptable first-line therapy, and neither has proven to be safer or more effective than the other in a direct comparison trial. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Harvoni is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 gastroenterology 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 56-year-old female enrollee has requested for chelation therapy for treatment of her lead and mercury toxicity.  Findings:  The physician reviewer found that this patient has not had blood metal testing for any toxin. In the absence of documentation of blood testing for lead and/or mercury levels, there is no evidence that the patient met clinical indications for chelation therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of the patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS guideline, RTC services were and are medically necessary for treatment of this patient. These findings give the patient a composite score which is consistent with medically monitored community based services. All told, the RTC services were and are medically necessary 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 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: Experimental/Investigational
Decision: Upheld

A 39-year-old female enrollee requested authorization and coverage of an endoscopic discectomy with the use of chemonucleolysis for the treatment of back pain.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that  an endoscopic discectomy with the use of chemonucleolysis is not likely to be more beneficial for treatment of the enrollees back pain than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication, estradiol 0.01% cream for complaints of burning with urination and suprapubic pain over the last two months. A urinalysis showed a white blood cell count of six to ten. Urine culture showed urogenital flora, consistent with contamination. There was no evidence of urinary tract infection. The prescriber diagnosed atrophic urethritis and recommended locally acting Estrace (estradiol) cream to decrease the side effects from oral formulations. This enrollee was prescribed topical estrogen cream for the treatment of atrophic urethritis. The enrollee was not prescribed Vagifem tablets because it is not the best treatment for her condition. This enrollees main complaint is burning pain with urination. Her urine culture did not indicate a urinary tract infection, and she did not have any other urinary symptoms (hematuria, urgency, hesitancy, incomplete emptying, enuresis, lower back or flank pain). Therefore, the next most likely diagnosis, given her age, is atrophic urethritis, also known as genitourinary syndrome of menopause.  The enrollees physician appropriately prescribed a topical estrogen cream for the enrollee to apply locally to the opening of her urethra. The medication Vagifem would not help alleviate this enrollees symptoms as well as the topical treatment. Typically, the best results occur when estrogen comes into direct contact with the urethra or any other specific area in need of treatment. While vaginal absorption of the Vagifem estrogen tablet may eventually have some benefits that extend to the urethra, typically, much higher doses of estrogen are needed for the benefits of local estrogen to transfer to the lower urinary tract. A study showed a minimum dose of 25 milligrams of estrogen, vaginally, was needed to see any beneficial changes in the urethral epithelial cells. This higher dosage of estrogen resulted in systemic increases in estrogen levels. There is concern that long-term systemic absorption of estrogen can increase the risk of endometrial cancer and venous thrombotic events. These risks are what the enrollees physician was trying to avoid when she wrote in her notes that she was using a topical estrogen, rather than an oral hormone supplementation, which has significantly higher risks associated with it.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 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 Dupixent solution pre-filled syringe 300 mg/2 mL.Dupixent is an interleukin-4 receptor alpha antagonist approved by the U.S. Food and Drug Administration for the treatment of adult patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies. There are very few treatments approved for this condition, and Dupixent has quickly become a standard therapeutic option in this setting. The data supporting its use in moderate-to-severe atopic dermatitis (eczema) is substantial, and it has a favorable side effect profile in comparison to other systemic agents. In this case, the patient has been diagnosed with moderate-to-severe eczema (atopic dermatitis). The patients condition has been difficult to control with various topical therapies. Based on all of the information provided, the patient appears to be a good candidate for this treatment. Therefore, Dupixent solution pre-filled syringe 300 mg/2 mL is medically necessary for treatment of the patients medical condition.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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old female enrollee has requested residential treatment services for treatment of the enrollees anorexia nervosa.  Findings:  The physician reviewer found that the American Psychiatric Association (APA) guidelines for treatment at different levels of care for patients with eating disorders indicate that in general, PHP is appropriate if the patients weight is greater than 80% of her ideal body weight (IBW). For treatment at the PHP level, only partial motivation is required, and the patient can be preoccupied with intrusive, repetitive thoughts more than three hours per day. The PHP level of care is also appropriate for patients that require some structure to gain weight, but do not need supervision at all meals. The records provided for review indicate this patient does not have any significant medical complications that would require hospitalization, and the patient is a candidate for treatment in a less restrictive setting than residential. From the description provided by the treatment team, this patient meets the APA criteria for treatment at the PHP level of care. Most PHP programs will supervise at least two meals daily, and some will supervise all three. All told, the residential treatment center services provided from the date indicated and forward are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old male enrollee has requested residential treatment center services for his alcohol abuse. Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the services at issue. As of the said date the patients vital signs were stable and he was participating in his care and was motivated to remain sober. He had shown improvement. He was not demonstrating any withdrawal symptoms.  He did not have any medical or psychiatric comorbidity.  He did not have any suicidal ideation.  He did not require 24 hour monitoring to insure his safety. Thus, the patient could safely have been treated at a lower level of care during the services in dispute. In sum, the patient did not meet the medical necessity criteria for residential treatment center services provided during the said timeframe.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for inpatient hospitalization services and prospective authorization and coverage for skilled nursing facility (SNF) services. The records indicate that this patient has a history of glioblastoma multiforme. There is evidence of progressive disease on imaging. The patient has completed at least one course of palliative chemotherapy and she is otherwise medically stable. Based on the available reports, there is no documentation of any skilled nursing needs to support SNF services. On physical examination, the patient is lethargic to obtunded. She currently lacks the ability to meaningfully participate in skilled rehabilitation. The patient has been fed via gastrostomy feeding tube for several months without issue and management of the gastrostomy tube does not require inpatient hospitalization or SNF level of care services. The records suggest that the patient is a candidate for custodial level of care services. Overall, there is a lack of indication for inpatient hospitalization services, or for prospective SNF services. Therefore, the inpatient hospitalization services and prospective SNF services were not and are not medically necessary for treatment of this patient. 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: Overturned

A 50-year-old male enrollee has requested magnetic resonance imaging (MRI) of the spine for evaluation of his back pain.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested diagnostic procedure in this patients case.  The current medical evidence supports the requested MRI in this clinical setting.  This patient continues to have right lower extremity radicular symptoms, including right thigh atrophy. While there has been some improvement, he continues to have intermittent burning, and abnormal right patellar reflex persists.  MRI is medically necessary in order to assess the cause of his symptoms and to determine whether any interventions may be beneficial.  All told, the requested MRI of the spine is medically indicated for the evaluation of this patient.