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 Orencia (1,000 mg intravenous (IV) loading dose following in one week by self-administered 125 mg weekly subcutaneous maintenance doses). The available records document that this patient developed psoriasis as a result of treatment with tumor necrosis factor inhibitor (TNFi) therapy with Humira. The patients provider indicated that alternate TNFi therapy such as Enbrel or infliximab should be avoided. In a retrospective study of patients who developed TNFi-induced psoriasis over a 10-year period, the authors reported that switching to an alternate form of TNFi therapy resulted in persistent or recurrent psoriasis in approximately 50% of patients (Mazloom, et al.). These findings are consistent with additional studies in the peer-reviewed medical literature. In addition, the U.S. Food and Drug Administration (FDA) indications state that treatment with Janus kinase (JAK) inhibitors including Rinvoq and Xeljanz carry the potential for major adverse cardiovascular events. This patient is noted to have several cardiovascular risk factors including obesity, hyperlipidemia, hyperglycemia as well as a family history of stroke in her mother and father. Moreover, the patient has a history of reported liver disease with transaminitis on laboratory testing. In light of the patients liver disease, her existing cardiovascular risk factors and the risk of major adverse cardiovascular events with Rinvoq and Xeljanz, avoidance of these medications is medically appropriate. According to the American College of Rheumatology (ACR) guidelines, Orencia is an acceptable FDA approved biologic disease modifying anti-rheumatic drug (DMARD) indicated for the treatment of patients with rheumatoid arthritis. Treatment with Orencia is appropriate for this patient given her preexisting cardiovascular risk factors, liver disease, and TNFi-induced psoriasis. Therefore, the requested Orencia (1,000 mg IV loading dose following in one week by self-administered 125 mg weekly subcutaneous maintenance doses) is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in rheumatology 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

The parent of a 15-year-old female enrollee has requested continued residential treatment services for treatment of the enrollees polysubstance abuse, major depressive disorder and borderline personality traits.  Findings:  The physician reviewer found that the patients history notes two inpatient admissions within two months associated with suicidal behavior, self-abusive behavior and substance abuse. The treatment team notes on the said date indicate that the patient continued to struggle with substance abuse urges.  The patient continued to have nightmares related to post-traumatic stress disorder.  Given the patients history and symptoms, impaired impulse control, comorbidity and repeat hospitalizations, she is at significant risk of decompensation outside of a highly structured 24-hour treatment setting.  In this patients case, the requested level of care is consistent with American Academy of Child and Adolescent Psychiatry practice parameters.  All told, continued residential treatment services are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 33-year-old male enrollee has requested continuation of psychotherapy treatment for the treatment of his panic disorder. Findings:  The physician reviewer found that this patient appears to be finalizing his treatment which has been beneficial. The goals for the final phase of treatment should include continued efforts to confront his fears, continued application of acquired skills and treatment gains, reduction of dependence on his treating provider, transference resolution, and termination of treatment. In consideration of the long-term treatment effort and relationship with his treating provider, it would not be appropriate to simply transfer the patient to another in-network provider to complete treatment. This final phase of treatment can reasonably be completed within six months of the date of this decision and should involve no more than 26 additional treatment sessions with his current provider. If the patient regresses and becomes more symptomatic during this final phase of treatment or subsequent to termination, an alternative treatment course should be pursued.
Appeal type: Experimental/Investigational
Decision: Overturned

A 43-year-old female has requested an electrical stimulator for treatment of her condition status post anterior cruciate ligament reconstruction.  Findings:  Two physician reviewers found that the patient has a history of left knee pain.  The patient underwent an anterior cruciate ligament reconstruction with allograft and microfracture abrasion arthroplasty.  Arthroscopic partial medial meniscectomy of the left knee was also performed. In this patients case, the requested electrical stimulator is likely to be more effective than other treatment modalities.  Neuromuscular electrical stimulation is used to treat muscle atrophy.  Its use is limited to the treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves, and other non-neurological reasons for disuse atrophy.  This patient is status post extensive ligament and microfracture surgery.  Pilot studies demonstrate a superior effect of electrical stimulation compared to physical therapy alone in this clinical setting.  The inhibition of muscle activation and reversal of atrophy has been demonstrated in this patient population.  Thus, the requested device is likely to be of greater benefit than other treatment options in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old female enrollee requested authorization and coverage of a home electrical stimulation unit for the treatment of pelvic floor weakness and incontinence. 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 electrical stimulation unit is not likely to be more beneficial for treatment of the enrollees pelvic floor weakness and incontinence 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cervical/thoracic facet joint block. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. The medical records do not document that the patient has responded with a 50% or greater reduction of pain following medial branch block of the cervical facet joints. Furthermore, the data concerning long-term pain relief using the requested procedure are conflicting and fall short of level I evidence. The current medical evidence does not support the requested services in this clinical setting. All told, the requested cervical/thoracic facet joint block is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar (CPT-22857), with posterior redo decompression left L4-5 and possible L5-S1. Findings:  The physician reviewer found that In this case, there are several concerns regarding the patient's condition. The patient has seen several physicians and there is not a consensus about her condition and the need for surgery. There is not a consensus about what the patients MRI testing shows, what her complaints are, or what her physical examinations have noted. The patient has a complex pain syndrome that is not made simpler by her complex regional pain syndrome and fibromyalgia. The patient's neuropsychological evaluation documented concerning, persistent psychiatric illness that could interfere with the outcome of her surgery . Moreover, the neuropsychologist specifically stated that traditional medical treatment will likely be unsuccessful in reducing the patients pain. Furthermore, the patient possesses several contraindications to the use of lumbar disc arthroplasty. The patient seems to have an isolated radiculopathy, or is at least felt to by her treatment surgeon. In addition, facet arthropathy is a contraindication to performance of arthroplasty, and the patients MRI reports mild facet disease, and the patients orthopedic surgeon reported significant facet arthropathy from L3-S1. In summary, lumbar disc arthroplasty remains a controversial procedure. The patient has seen several providers, and there is variability in their assessments. There are also some contraindications to spine surgery in general, and to lumbar disc arthroplasty specifically. Under these circumstances, the requested total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar (CPT-22857), with posterior redo decompression left L4-5 and possible L5-S1 is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.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: Experimental/Investigational
Decision: Overturned

A 25-year-old female enrollee requested patent foramen ovale (PFO) closure for medical treatment of her medical condition. Findings:  Two physician reviewers found that the request for PFO closure is likely to be more effective for this patient than other available options. The patient is a young, active female who had a transient ischemic attack and subsequent work-up demonstrated PFO with significant right to left shunt. Recent studies and meta-analysis have favored PFO closure especially using the Amplatzer device versus medical therapy, especially in young patients such as in this case (Stortecky, et al). For the reasons provided, the requested closure of a patent foramen ovale is likely to be more beneficial for treatment of the patients medical condition than any other modalities.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old female enrollee has requested Botox injections for treatment of her temporomandibular joint disorder (TMJ).  Findings:  Three physician reviewers found that review of the submitted documentation and literature fails to demonstrate that the services at issue were likely to be more beneficial for treatment of the patients medical condition than standard therapies. Review of the medical literature available does not provide conclusive results that Botox is a safe and effective treatment for TMJ. Although the U.S. Food and Drug Administration (FDA) have approved Botox for migraine headache and cervical dystonia, it has not approved its use for TMJ, (National Institute of Dental and Craniofacial Research). In addition, the American Dental Association has not established a standard of care concerning the off brand use of Botox to treat TMJ. For the reasons set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy based on the available research.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar spinal fusion (CPT codes: 63047, 63048, 22630, 22632, 77002, 22612, 22614, 22842 and 20936) and one day inpatient stay following the lumbar spine surgery. Findings:  The physician reviewer found that per the North American Spine Society (NASS), lumbar fusion is indicated for patients with specific diagnoses with qualifying criteria when appropriate. In this case, there is lack of evidence on MRI demonstrating severe spinal stenosis or radiographs demonstrating segmental instability to warrant the requested revision lumbar fusion. As there is a lack of medical documentation demonstrating a pattern of radiculopathy/neurogenic claudication explained by the imaging findings, stenosis resulting in functionally limiting motor weakness, and 6-12 weeks of non-operative treatment has been performed, the requested lumbar spinal fusion (CPT codes: 63047, 63048, 22630, 22632, 77002, 22612, 22614, 22842 and 20936) and one day inpatient stay following the lumbar spine surgery is not supported as medically necessary for treatment of this patients low back pain. 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 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 39-year-old female enrollee has requested NeuroStar Transcranial Magnetic Stimulation (TMS) therapy for treatment of her major depressive disorder. Findings: Two physician reviewers found that the records show that her depression is treatment resistant since multiple anti-depressant medications from various classes have not successfully brought on remission. In the clinical studies, Schutter and colleagues reported that TMS had a moderate effect on treatment resistant depression (Schutter, et al). In addition, George and colleagues demonstrated that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. Moreover, Avery and colleagues provided evidence that TMS is a safe and effective treatment for major depressive disorder. Thus, although relatively new, TMS is effective treatment for patients with treatment resistant MDD. As it is FDA approved for the treatment of treatment-resistant MDD, consistent with standards of good medical practice, I have concluded that TMS is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for modafinil 100 mg for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). Findings:  The physician reviewer found that as noted in the medical literature, stimulant medications are considered the gold standard pharmacologic intervention for attention deficit hyperactivity disorder (ADHD). Per the American Psychiatric Association (APA), stimulants such as methylphenidate and amphetamine salts are the two major categories of pharmacological treatment for ADHD and are considered the first-line medication treatments for the disorder. Modafinil is not a stimulant, rather it is a wake promoting agent that selectively increases neuronal activity in the hypothalamus, particularly in the wakefulness center of the tuberomammillary nucleus. The medication is approved by the U.S. Food and Drug Administration (FDA) for excessive sleepiness associated with narcolepsy, obstructive sleep apnea and shift-work sleep disorder. Due to several promising studies, the FDA considered modafinil for ADHD in 2006, but due to concerns of Stevens-Johnson syndrome and the absence of rigorous scientific trials demonstrating the long-term safety and efficacy of the medication, modafinil is not recommended for treatment of ADHD. In this patients case, there is no evidence in the records that formulary equivalents would be inappropriate, unsafe or inadequate. Indeed, the patient did well with Dexedrine for at least 10 years, and it appears that the medication, as well as newer FDA approved options such as lisdexamfetamine and dexmethylphenidate, are on the formulary and available to this patient. Additionally, there is no interpretative summary or clinical rationale in the medical documentation that supports atypical dosing of modafinil for ADHD. 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for image-guided bilateral sacroiliac joint injection including arthrography. Findings: One study noted that, various studies have reported that three or more than three provocation tests might provide a more sensitive and specific identification of the stress from the sacroiliac joint. The authors concluded that, A diagnostic sacroiliac joint block helps to establish a more accurate diagnosis of intra-articular sacroiliac joint pain. Another study stated that diagnosis of sacroiliac joint dysfunction was made with three or more positive provocation tests, with the highest sensitivity being Faber (91.4%) and lowest probability was Gaenslen test. The authors also stated that the proposed criteria for diagnosis of sacroiliac joint dysfunction, which includes pain in the area of the sacroiliac joint, reproducible with provocative maneuvers, and must be relieved with local anesthetic injection into the sacroiliac joint or the lateral branch nerves. In this case, the patient has chronic low back pain with mixed examination findings of positive findings on two sacroiliac joint provocation maneuvers along with positive back pain reproduced with lumbar facet joint loading. Based on the most recent evidence-based guidelines regarding the clinical diagnosis of sacroiliac joint related back pain, at least three provocative maneuvers are required to establish strong suspicion for sacroiliac joint back pain. Furthermore, the providers impression was an L5 facet issue, which supports a pain generator above the L5 vertebral body, or the facet joint. There is a lack of evidence in the literature to support performing an SI joint injection on a patient with suspected facet joint related back pain. Given these findings, the requested image-guided bilateral sacroiliac joint injection including arthrography is not medically necessary for 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 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

A 44-year-old female enrollee has requested for a lymphedema pump for treatment of his venous stasis dermatitis.  Findings:  The physician reviewer found that the use of the pneumatic compression device in the setting of chronic venous insufficiency remains controversial. However, in this patient it is medically necessary because this patient has failed to improve despite very significant weight loss, an aggressive use of diuretics, elevation, and the regular use of compression stockings. A brief trial of pneumatic compression in the past was helpful in relieving her symptoms, and is thus likely to be helpful for her now.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment for treatment of her behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  This patient had struggled with eating disordered behavior.  Her symptoms had worsened in 2016 and resulted in physical sequelae, and both psychiatric and medical comorbidity.  Despite residential and inpatient care, the patient continued to struggle with her eating habits.  Per the records, the patient continued to subscribe to rigid eating disordered schemas.  The patient was overheard vomiting.  She continued to engage in food rituals and restrict her intake until discharge.  In sum, despite her treatment up to that point, the patient had not yet consolidated the treatment gains necessary to succeed in a less restrictive setting.  The residential treatment provided was safe, appropriate and consistent with good medical practice.  The duration of services for a case of this complexity was consistent with community standards.  Finally, the entire course of care was reasonably expected to improve her condition and prevent a more serious episode of illness.  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.