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 seat elevation, mounted cup holder, LED lights, and upgraded wheelchair motor (4-pole 12.5 KPH/8 MPH) to be added to his already approved powered wheelchair. In this case, the patient has retained sufficient upper limb function to perform some tasks, such as eating and using a telephone. As such, a mounted cup holder with an adaptive straw is medically necessary as it would allow the patient to hydrate at will, independently, which he would not otherwise be able to do. Researchers note that there is little data available to support standards development related to independent wheelchair transports. While seat elevation may assist a user to independently transfer, the available records do not indicate that this patient  would be able to safely perform independent transfers by utilizing the downhill gradient afforded by a power seat elevation. There is no documentation of any transfer trials with physical or occupational therapy. Optimizing lighting, whether through ambient adaptations or lighting equipment on a wheelchair, are generally highly advisable. However, such measures address environmental concerns and are not medically necessary for mobility-related activities of daily living and thus are not medically indicated. A motor beyond the base group 3 power mobility device motor is likewise not medically necessary for accomplishing mobility-related activities of daily living. Therefore, a mounted cup holder to be added to the already approved powered wheelchair is medically necessary for the treatment of this patient, while seat elevation, LED lights, and an upgraded wheelchair motor (4-pole 12.5 KPH/8 MPH) are not medically necessary.Final Result: The reviewer determined that the requested equipment is partially medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.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: Upheld

The parents of a 4-year-old female enrollee requested authorization and coverage of referral and surgery (The Leonard Procedure for Pectus Carinatum) for the treatment of pectus carinatum.  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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Nuvigil. Findings:  The physician reviewer found that the submitted records and relevant literature fails to demonstrate the medical necessity of the requested medication. The documentation provided for review does not support the diagnosis of shift work sleep disorder. In addition, there is a lack of documentation showing that the patient is employed in an occupation which necessitates shift work. There is also a lack of evidence showing the presence of other sleep disorders such as obstructive sleep apnea or narcolepsy. 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 neurology with sub-specialty certification in sleep 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: Upheld

A 56-year-old female enrollee has requested for a total ankle replacement for treatment of her post-operative and degenerative joint disease.   Findings:  Two physician reviewers found that Total ankle arthroplasty is an accepted medical procedure with good results in selected patients. Whether the long-term results (greater than 10 years) are durable, or are better than arthrodesis has been the subject of a long running clinical debate that has yet to be answered. These implants are FDA approved and have been shown to provide pain relief and restore motion in a severely arthritic joint. All told, there is adequate evidence of the efficacy of total ankle arthroplasty to support its use in this case.
Appeal type: Urgent Care
Decision: Overturned

The parent of an eight-year-old female enrollee has requested emergency services for the treatment of the enrollee's condition. Findings:  The physician reviewer found that the enrollee was suffering from acute abdominal pain. Although it is difficult to assess the severity of pain as it was reported as crampy and intermittent, the mother reports that at one point, the pain was so severe that she was not able to walk or stand up. In addition, the physicians caring for her had a broad differential diagnoses to rule out including volvulus, appendicitis, urinary tract infection and others. Many of these conditions can be medical emergencies that are life-threatening if diagnosis is delayed. It is reasonable that a prudent layperson would choose to seek immediate emergency medical evaluation for abdominal pain of such severity due to potential jeopardy to her health or function.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old female enrollee has requested the real-time heart monitor for evaluation of her premature ventricular contractions.  Findings:  Two physician reviewers found the services at issue were not likely to have been of greater benefit than other available methods of evaluation.  This patient presented with symptomatic palpitations and head fullness that were occurring frequently.  She had previously been demonstrated to have PVCs.  There was no record of syncope and no evidence of structural heart disease based on the medical records provided.  In this clinical scenario, the utilization of standard outpatient monitoring systems such as a standard Holter or 30-day loop monitor would have been expected to provide the clinical information required for assessment of the patients symptoms.  Thus, the use of the real-time heart monitor was not likely to provide better health benefits when compared to the more standard monitoring techniques.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old male enrollee, with painful peripheral neuropathy, has requested authorization for the medication Lyrica. Findings:  The physician reviewer found that painful diabetic neuropathy is a surrogate for small fiber neuropathies; medications that help pain for one are invariably effective for the other. The patient has found Lyrica 300mg twice daily to be substantially more effective than previous therapies in controlling his pain. As such, continued use of Lyrica is medically appropriate and clinically indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested inpatient acute rehabilitation services for the treatment of her cerebrovascular accident. Findings: The physician reviewer found that in this clinical setting, inpatient acute rehabilitation services are not medically necessary for treatment of this patients medical condition.  Per standards of care in the practice of rehabilitation medicine, acute inpatient rehabilitation is not necessary if appropriate care meeting a patients clinical and rehabilitation needs can be provided at a less intensive level of care. Functional impairments due to acquired brain insults such as stroke can improve with time, i.e., natural recovery processes; but, are also amenable to rehabilitation interventions. The role of inpatient rehabilitative care for persons with significant functional deficits following stroke is relatively well-established in the medical literature. In the present case, the patient had very profound initial functional deficits following her stroke. She received acute inpatient rehabilitation care and made limited progress. She has now been receiving care at the skilled nursing facility level and has been making functional progress. This functional improvement is due in part to natural recovery processes following stroke, as evidenced by the fact that the patient has continued to make progress more recently despite reduced therapy intensities. Additional recovery and functional improvement are expected. Ongoing rehabilitative management however, does not require an acute inpatient rehabilitation setting of care. In this case, there are no documented ongoing skilled nursing needs: no complex wound care, no initiation of self-care related to enteral feeding or ostomy care. In sum, the requested inpatient acute rehabilitation services 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 physician 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: Upheld

A 51-year-old female enrollee has requested for the prescription medication Tazorac for treatment of her skin condition. Findings:  The physician reviewer found that Tazorac is not considered standard treatment for vitiligo.  There is no evidence in the medical records submitted establishing why this off-label intervention is being utilized over standard treatments.  In addition, there is no evidence demonstrating that the patient has attempted and failed available standard treatments or that standard treatments are contraindicated. As such, the medical records do not support use of this medication for this patient at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 24-year-old male enrollee has requested  residential treatment center (RTC) services for treatment of his history of seizure caused by withdrawal from drugs.   Findings:  The physician reviewer found that on the date indicated, the patient reported that he was not experiencing any withdrawal symptoms. The records provided for review do not indicate that the patients reported seizure was due to abrupt discontinuation of benzodiazepines. The patient endorsed using Xanax 2 mg three to four times per week mixed with alcohol. His last reported use of alcohol was approximately two weeks prior to admission. By the date indicated, any alcohol would have been out of his system. Further, his last reported use of Xanax was on the date indicated, which was five days prior to his seizure. Given that the half-life of Xanax is approximately 11 hours, using 2 mg, at five days after his last use, the drug would be virtually out of his system. In addition, the patients vital signs were stable and he did not have any other reported biomedical complications or history. The patient did not have a diagnosed psychiatric illness but he did report anxiety and depression. He did not attest to suicidal or homicidal ideation, intent, or plan. There was no psychotic ideation, he was not a danger to himself or others, and there was no evidence of functional impairment in his activities of daily living. He demonstrated motivation to engage in recovery, and participated actively in the group processes and 12 steps. He was gaining insight into his relapse potential. It is the standard of care to perform benzodiazepine withdrawal on an outpatient basis. Based on these findings, the patient does not meet the American Society of Addiction Medicine (ASAM) criteria for RTC level of care. All told, this patient does not require 24-hour supervision and treatment in a RTC setting. Therefore, the RTC 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 thirty-five year-old female with diagnoses of eating disorder NOS, severe recurrent depression and character disorder is requesting reimbursement and prospective authorization of a partial hospitalization program.Reviewers Findings:  The reviewing physician found that successful treatment requires a treatment plan with measurable objectives, a program able to carry out those objectives and a patient who is motivated to participate in the program.  There is little evidence to suggest that this patient is motivated to cooperate in a program such as this one.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for lumbar microlaminectomy.In this case, there is objective evidence of lumbar stenosis and neural compression noted in the patients MRI report. MRI of the lumbar spine noted moderate to severe central canal stenosis at L3-4 and mild central canal stenosis at L4-5. Central stenosis due to broad-based disc herniation and ligamentum flavum thickening, as well as bilateral foraminal stenosis were noted at the L3-4 and L4-5 levels. In addition, the patient has a long history of low back pain in which nonoperative treatment has failed to provide relief. At this time, the patient reports numbness when sitting or standing, and his pain level has increased. Under these circumstances, the requested lumbar microlaminectomy is medically necessary for treatment of the patients medical condition.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 neurological 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for frovatriptan succinate 2.5 mg tablets for treatment of the enrollees chronic migraines. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  The medical records indicate inadequate responses to the preferred agents of Zomig, Maxalt and Imitrex. Thus, there is documentation that three of the preferred medications have been tried. The current medical evidence supports frovatriptan succinate in this clinical setting. Therefore, the requested frovatriptan succinate 2.5 mg tablets are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old male enrollee has requested cervical discography for evaluation of his pain.   Findings:  The physician reviewer found that cervical discography is medically necessary for evaluation of this patients pain.  The patient had multiple cervical spine surgeries that moderately controlled his pain until his recent motor vehicle accident. Additionally, the MRI and CT scan of the cervical spine are significant for multilevel disease, making it difficult to determine the true pathological cause of his pain. Trigger point and epidural steroid injections only provided temporary relief of pain. The patient is in need of a more definitive intervention in order to treat his symptoms. Cervical discography would guide the provider in choosing the best intervention to appropriately treat the patients medical condition.Manchikanti and colleagues performed a systematic review of the medical literature on cervical discography to evaluate the validity of cervical provocation discography in managing and diagnosing discogenic pain. They concluded that cervical discography performed according to the International Association for the Study of Pain criteria may be a useful tool for evaluating chronic cervical pain.   Zheng and colleagues performed a retrospective study to compare the value of cervical MRI versus discography in selecting the level for discectomy and fusion and to evaluate surgical outcome. They concluded that MRI has relatively high false-negative and false-positive rates. Discography can prevent the levels from being unnecessarily fused.  The combination of clinical symptoms, MRI and discography provides the most information for decision making and can improve the management of cervical discogenic pain.  All told, the requested cervical discography is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

The mother of a 14-year-old female enrollee requested authorization and coverage of continued intravenous Rocephin therapy for the treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested therapy is not medically necessary for the treatment of the enrollees Lyme disease.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old male enrollee has requested a 90-day program for treatment of his alcohol dependency.  Findings:  The physician reviewer found that this patient entered a 90-day RTC program for his alcohol dependence. Several years prior, he was in an outpatient program for his alcohol dependence, but this was unsuccessful as he had an immediate relapse. He has not attempted any other treatments for his substance abuse issues. Another significant factor in this patients case is that he had no significant psychiatric issues (comorbidities) present. Comorbidities are typically a key indicator for an individual to receive a higher level of care (Level of Care Utilization System (LOCUS) and American Psychiatric Association (APA) practice guidelines). In cases such as this, an evidence-based, objective, instrument such as the LOCUS can be helpful in determining a patients necessary level of care. This patient scores on the LOCUS as follows: 1) Risk of harm  low; 2) Functional status  moderate; 3) Medical, Addictive and Psychiatric Co-Morbidity  minor; 4A) Recovery environment  moderate; 4B) Recovery environment, level of support - supportive-limited; 5) Treatment and Recovery history  moderate; and 6) Engagement and Recovery status - positive. This gives the patient a composite score of 17-18 which correlates with a treatment intensity level of three which is, high intensity community based services. An example of this treatment setting is clinic-based treatment services. Furthermore, the patients substance abuse issues did not meet APA practice guidelines for RTC level of care as it is not established that he lacked sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. In summary, this patient could have been treated safely and effectively at a less restrictive setting during the period at issue. He did not meet criteria for RTC services based on two different evidence-based level of care instruments (LOCUS and APA).
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha Sureclick 140 mg/mL for treatment of the enrollees coronary heart disease. Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication. The medical records document significantly increased coronary risk, but no symptoms or objective findings indicative of coronary vascular disease and no confirmed diagnosis of homozygous or heterozygous familial hyperlipidemia.  These diagnoses require not only elevated LDL levels that significantly exceed 180 mg/dl, but also a combination of physical examination findings (arcus cornealis below the age of 45, tendon xanthomata), a family history of premature coronary disease (younger than 50 years in second-degree relative or aged younger than 55 to 60 years in first-degree relatives) and documented genetic defects related to cholesterol metabolism according to published criteria.  The documentation does not support the patient meets criteria for this diagnosis.  Praluent is a PCSK9 inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol.  This patient does not meet any of those criteria. PCSK9 inhibitors have not been studied in other patient populations, such as this patient. Current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting.  Therefore, the requested Repatha Sureclick 140 mg/mL  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 with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female enrollee requested authorization and coverage for a Magnetic Resonance Imaging (MRI) study of her knees to diagnose and treat knee pain.  The enrollees health plan denied the request indicating the requested MRI 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 MRI is not medically necessary.