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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral lumbar transforaminal epidural steroid injections. Findings:  The physician reviewer found that records provided for review document that this patient has a history of chronic low back pain and bilateral radicular pain in the lower extremities. The provider documented that the patient previously benefitted from epidural steroid injections with over 50% improvement in pain for three months. Low back pain with bilateral radicular pain is commonly attributed to a combination of mechanical, inflammatory, and immunological causes. Epidural injections of steroids have been shown to reduce the inflammatory component of this process, with improvement in reports of pain and function. Although the caudal, interlaminar, and transforaminal approaches have been tried, the transforaminal approach under fluoroscopic guidance makes a targeted delivery of the steroid to the inflamed nerve root to achieve a superior result. Viswanathan and colleagues performed a literature review of 108 publications. The authors found that the overall success rate of the transforaminal lumbar epidural steroid injections ranged from 76% to 88% in the management of lumbar radicular syndrome. Given these findings, the requested bilateral lumbar transforaminal epidural steroid injections are medically necessary for 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 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: Experimental/Investigational
Decision: Overturned

A 56-year-old female enrollee requested authorization and coverage of total ankle replacement of the right ankle. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees ankle arthritis.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested procedure is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested procedure is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested open nasal reconstruction surgery for treatment of his nasal obstruction.  The physician reviewer found that the request for open nasal reconstruction surgery is medically necessary for treatment of the patients medical condition. In this case, the patient presents with a post-traumatic septal/nasal deformity producing a crooked nose and airway obstruction. A crooked nose typically produces an abnormal nasal airway and nasal airway obstruction. Open nasal reconstruction surgery is medically necessary to correct the patients deviated dorsum and airway obstruction. Given that the spreader graft was placed on the right side, and not the left side the patients nose is likely still deviated. For the reasons provided the request for open nasal reconstruction surgery is medically necessary in this clinical setting.  Final Result: The reviewer determined that the requested surgery 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 otolaryngology and plastic and reconstructive surgery with sub-specialty certification in facial plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 24-year-old female enrollee requested a prophylactic knee brace for medical treatment of her anterior cruciate ligament (ACL) rupture.  Findings:  The physician reviewer found that current evidence does not support the recommendation of using a functional knee brace after ACL reconstruction. Studies of patients who have stable knees after surgery do not show that bracing results in superior outcomes with prevention of further injuries. Mayr and colleagues reported that post-operative use of a stabilizing knee brace after ACL replacement showed no advantage over treatment without a brace at 4-year follow-up. The authors concluded that The use of a knee-stabilizing brace after isolated ACL reconstruction with autologous patellar tendon graft is not recommended. Given these findings, the requested prophylactic knee brace to prevent further injury is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a 4-year-old male enrollee requested authorization and coverage of speech, occupational, and sensory therapy for the treatment of a developmental articulation defect.  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

An 18-year-old male enrollee has requested reimbursement for Adolescent Mental Health Residential Treatment.  Findings:  The physician reviewer found that on review of the patients psychiatric evaluation on admission to the RTC, he was described on MSE as being cooperative, well groomed, and calm, with a good sense of humor, logical thoughts and no current or acute suicidal or homicidal ideation. The provider also noted that the patient was motivated for treatment. Progress notes dated four days later describe full affect, no auditory or visual hallucinations, and no suicidal or homicidal ideation. Six days from the progress notes referenced above, the patients mood was described as stable and on the next day the provider noted a bright affect with no suicidal or homicidal ideation. Five days from the previous entry, it was noted that the patient was socializing with peers and was compliant with treatment. Based on the Child and Adolescent Level of Care Utilization System (CALOCUS) criteria and the American Academy of Child and Adolescent Psychiatry (AACAP) treatment guidelines, this patient was a candidate for a less restrictive level of care during the period under review. These guidelines recommend treatment in the least restrictive setting possible, and given this patients symptoms, he would have been safely and adequately managed in an intensive outpatient program (IOP). For these reasons, the medical necessity for residential level of care has not been established.
Appeal type: Medical Necessity
Decision: Upheld

The patient is 62-year-old male with severe osteoarthritis of the knee. A request has been made for a BioniCare unit to treat the patients arthritis. The Health Plan has denied the request on the basis the requested device is not medically necessary for treatment of the patients knee pain.The requested device is not a standard treatment protocol for patients with arthritic conditions. The efficacy of the BioniCare device for this clinical indication has not been established. There are no long-term prospective studies supporting the use of this device for patients such as this patient. There are other treatment modalities available to manage the patients pain. Therefore, I have determined the requested device is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for dual diagnosis residential treatment center (RTC) level of care services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for clinically managed high-intensity residential services. Applying the ASAM guidelines, the patient is at risk for subacute protracted withdrawal. The records document physical and psychological symptoms including sweating, tremor, agitation, and anxiety. These symptoms, combined with intense cravings and poor coping strategies, place him at high risk of relapse outside of a structured setting. Continued substance use places a serious risk to the patients health, as evidenced by a recent car accident, abscesses related to intravenous drug use, and related risky sexual behaviors. The patients mental status is sufficient to permit participation. However, he is unable to control his substance use without 24-hour support, unable to control his impulses and is at imminent risk of relapse if discharged. He does not possess the impulse control required to cope with his emotions and gain new healthy coping strategies to maintain sobriety. The patient has demonstrated opposition to addressing his substance use disorder. He requires structured therapy and the 24-hour milieu due to his impaired perspective and inability to make sound decisions. The patient has been unable to identify his relapse triggers without guidance by staff and reports severe use cravings. He has social stressors involving his mother and not seeing his daughter, which have been prior triggers to relapse. The patient lacks a healthy, supportive family network. Given these findings, dual diagnosis RTC level of care services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 psychiatry with expertise in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Fiasp 20 units per day and Tresiba 12-14 units per day. Type 1 diabetes is a chronic autoimmune disease characterized by insulin deficiency and resultant hyperglycemia. Although insulin remains the mainstay of therapy, new insulin analogues with varying onsets and durations of action are widely available. Optimal glycemic control requires multiple-dose insulin regimens that mimic physiological insulin release, with basal insulin for overnight and between-meal control, plus bolus doses of rapid-acting insulin analogues to cover ingested carbohydrate loads and treat hyperglycemia. To optimize glycemic control, new insulin options have been introduced for routine patient use. Basal insulin analogs with longer duration, such as Tresiba, have demonstrated efficacy in maintaining metabolic control without hypoglycemia, especially during the night. Likewise, new ultra-rapid prandial insulin analogs, such as Fiasp, have led to better postprandial glycemic control reducing hyperglycemia in the early post-prandial phase. This patient requires approximately 12 to 14 units of Tresiba and 20 units of Fiasp per day in order to optimize her glycemic control for her type 1 diabetes. The provider reports that the patient has been treated with Fiasp 4-6 units per meal and Tresiba 12 units per day with Farxiga 5 mg per day with reasonable control of her diabetes. Given these findings, the requested Fiasp 20 units per day and Tresiba 12-14 units per day are 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 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

A 43-year-old male enrollee is requesting surgical removal of an eye lesion for the treatment of his pterygium. Findings:  The physician reviewer found that surgical removal of pterygium has a significant rate of recurrence. It would be prudent to try conservative therapy and observe the patient for signs of growth. Pterygium is a benign lesion that is very common. In a small number of cases, the growth may approach the pupil and require surgical removal. This does not appear to be happening in this patients case. As such, there is currently no clinical indication for the proposed procedure.
Appeal type: Experimental/Investigational
Decision: Upheld

A 35-year-old female enrollee has requested MRI-guided high-intensity focused ultrasound ablation (MRgFUS) for the treatment of her uterine fibroids. Findings:  Three physician reviewers found that MRgFUS is a uterine sparing outpatient procedure that uses high doses of focused ultrasound waves to destroy the myomas without affecting any other tissue around the fibroid. Uterine fibroids are a significant health problem for women. The gold standard of treatment, especially for large symptomatic myomas is a hysterectomy or myomectomy. Given this patients desire for a uterine sparing procedure, a hysterectomy is not indicated. However, there is no contraindication to myomectomy. Although MRgFUS shows promise as a safe, non-invasive alternative to standard therapy, there is no long-term data in the current evidence-based medical literature that shows this procedure improves health outcomes, is as good as or better than the standard alternatives or shows long-term improvement outside the research setting.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old male enrollee has requested Supartz injections for the treatment of his osteoarthritis. Findings:  The physician reviewer found that viscosupplementation has a documented moderate positive effect on patients with osteoarthritis of the knee. The Health Plan has reasonable requirements that first-line treatments be tried prior to viscosupplementation, and the patient has not yet met this criteria. There are no documented contraindications to the therapies recommended by the Health Plan. Therefore, the requested therapy is not medically indicated or appropriate for this patients care absent a trial of the above-mentioned first-line treatments.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Enbrel for treatment of the enrollees plaque psoriasis. Findings:  The physician reviewer found that Given the location of plaque psoriasis on the scalp, ultraviolet light therapy is not feasible. In addition, the use of acitretin and methotrexate in a female of child-bearing potential is not recommended. The use of cyclosporine may be used for an acute flare of psoriasis, but given the long-term risks of the medication on renal function, this is not an adequate long-term treatment plan. Moreover, the use of anti-tumor necrosis factor (TNF) agents such as Enbrel are considered first-line therapy for psoriasis when systemic treatment is necessary. In this clinical setting, Enbrel for the treatment of scalp psoriasis is medically reasonable and appropriate. Accordingly, the request for Enbrel has been established as 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: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Ajovy. The patient has experienced migraines since the age of five. The patient has used multiple abortive and preventive medications, but reports they were not effective. The patient reports her headaches are severe and that symptoms have been present for ten years. The headaches occur four to six times per week and last 25-48 hours. The patient is currently on metoprolol and Botox injections, but the provider wants better control and is requesting Ajovy. Ajovy is approved by a governmental body for the prevention of migraine headaches. The medical literature notes medication Ajovy is recommended for the treatment of chronic migraine headaches. Literature also noted that patients who had failed up to four classes of medications found Ajovy effective. The patient's symptoms were inadequately controlled with metoprolol, Botox, Topamax, tramadol, Wellbutrin, Tylenol Ibuprofen, and Imitrex.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 neurology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment. The submitted documentation fails to demonstrate the medical necessity of the services at issue. At the time of denial of coverage, the patient had participated actively in treatment. She had stabilized her weight and was not purging or binging.  Treatment goals can often effectively be accomplished in the outpatient setting. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) may assist in determining necessary level of care for children. With regards to risk of harm, the records support a score of 1. This patient demonstrated a low potential for risk of harm. She had no history of violence toward others. In terms of functional status, the records support a score of 1. The patient was engaged and active in treatment, not known to be purging or restricting. With regards to comorbidity, the documentation supports a score of 2. The patient had minor comorbidity. In terms of level of stress of the recovery environment, the records support a score of 1. There is no evidence of environmental threats, deprivation, or lack of financial support. With regards to level of support of the recovery environment, the records support a score of 2. The patients parents had recognized concerns regarding the patients weight, and had financially supported her treatment. In terms of resiliency and treatment history, the records support a score of 1. The patient was fully engaged with treatment per progress notes. With regards to acceptance and engagement of the patient, the records support a score of 1. Per the records, the patient was engaged and motivated for success in treatment. In terms of acceptance and engagement of the parent, the records support a score of 3. Per the patients report, her parents appeared to be judging rather than listening. Therefore, the patient has a composite score of 12, with no scores in the high risk range. Thus, the records do not support the medical necessity of residential treatment in this case. Therefore, residential treatment was 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 with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee has requested additional physical therapy treatments for treatment of her low back pain and difficulty walking.  Findings:  The physician reviewer found that based on the functional gains observed in physical therapy during the course of treatment, new long-term goals were established and additional therapy sessions were requested. The patient has demonstrated an excellent response to the therapy program and had progressed from a non-ambulatory status to ambulatory with use of an assistive device. It is reasonable to expect that the patient has the potential to progress further. Additional gait training without an assistive device and on uneven surfaces was planned. The patient has not plateaued functionally and has the potential to make further significant gains.  Thus, the requested additional physical therapy treatments are medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 19-year-old male who has had severe extensive psoriasis for the past two years. The psoriasis, at its worst, covered 81% of his body surface and was severely painful. Cyclosporine had to be discontinued because of severe headaches. His dermatologist stated that methotrexate and Soriatane are contraindicated because of a history of liver problems. The manufacturers protocol for ultraviolet therapy states that this treatment is contraindicated if the patient has psychological problems. Coverage for Enbrel was denied by the Health Plan in 2004. Coverage for Raptiva was recently denied by the Health Plan as not medically necessary.The treatment alternatives required by the Health Plan are contraindicated according to this patients medical history. Severe headaches from cyclosporine rule this drug out. Additionally, the patients provider indicates the patient has a history of liver problems. Although there may be no objective evidence of liver disease currently, the patient would be at risk for liver problems from methotrexate or Soriatane.  Furthermore, the manufacturer of the UVA equipment warns against that therapy for patients with psychological problems. The Health Plan has denied coverage for Enbrel. At this point, it is imperative that this patient be treated for his extensive and severe psoriasis. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.