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

A 62-year-old female enrollee has requested Lyrica for treatment of her peripheral neuropathy. Findings:  The physician reviewer found that this patients symptoms are highly suggestive of neuropathic pain, which could be secondary to the abnormalities in her thoracic spine. In addition, the pain described by the patient correlates well with the anatomical location of this abnormal finding. Lyrica (pregabalin) is a calcium-channel modulator which has been approved for the management of neuropathic pain due to diabetic neuropathy, post-herpetic neuralgia and fibromyalgia. It has been used off-label for many other neuropathic pain conditions including complex regional pain syndrome (type I and II) as well as post-laminectomy pain syndrome and spinal cord injury. A similar medication (Neurontin) was previously tried by this patient, but caused side effects requiring discontinuation of the medication. Based on this patients excellent response to her prior trial of Lyrica, its lack of side effects and its very low risk (as opposed to surgery or spinal cord stimulation trialing and implantation), the requested medication is medically necessary to treat this patients symptoms of peripheral neuropathy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Divigel 1 mg/gram (0.1%) gel packet for treatment of the enrollees menopausal symptoms.  Findings:  The physician reviewer found that according to a study, Once a decision has been made to treat a postmenopausal woman with estrogen, consideration should be given to the type of estrogen and the route by which it is to be given, as well as the need for progestin and the most appropriate progestin regimen. Estrogen is available in many forms: oral, transdermal, topical gels and lotions. The potency and therefore the doses of these estrogen preparations differ, but they differ little in efficacy. The documentation provided for review does not show that the patient has tried any of the Health Plans formulary alternatives. In addition, various patches may use different adhesives, so one might be tolerated when another was not. An oral option eliminate the possibility of skin reactions. 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for psychiatric acute inpatient care. The submitted documentation supports the medical necessity of the services at issue. The progress notes indicate that the patient had daily episodes of agitation and aggression toward staff. She was given as needed medications on a daily, and often several times per day, basis. The progress notes indicate that the patient would attack staff without provocation. Per the records, her behaviors could not have been managed in a less restrictive setting due to her level of aggression and need for immediate medical intervention, including seclusion and as needed medications.The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. With regards to risk of harm, the records support a score of 4 due to her recent pattern of striking staff and biting herself. In terms of functional status, the records support a score of 5 due to numerous disruptions in her home due to her behaviors and symptoms. With regards to comorbidity, the records support a score of 4. The patient has significant psychiatric symptoms that impair functioning in the absence of stressors. In terms of level of stress of the recovery environment, the records support a score of 2. The patients home life is overall stable. With regards to level of support of the recovery environment, the records support a score of 2. The patients family is supportive. In terms of resiliency and treatment history, the records support a score of 5. The patient has not demonstrated significant remission of symptoms in the recent past. With regards to acceptance and engagement of the patient, the records support a score of 5. The patient showed almost no insight into her behaviors due to her profound impairment. In terms of acceptance and engagement of the parent, the records support a score of 2. The parent worked well with clinicians. Thus, the patient has a composite score of 29. This score correlates with secure 24-hour services with psychiatric management. The medical evidence supports the services at issue in this clinical setting. Therefore, psychiatric acute inpatient care was medically necessary for the 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 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

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that in child development, delay in speech acquisition is an important predictor for later problems. Research over the past 50 years has yielded several promising approaches and many specific intervention techniques designed to enhance the communication and language development of young children with intellectual and developmental delays and disabilities. In the clinical literature, Gallagher and Chiat found that, Studies of children with language impairment have reported emotional and behavioral problems in 50-75% of that population. In addition, various authors describe children with delayed speech development as being at high risk for other cognitive, social-emotional, and school-related problems. As such, language development is one of the most significant processes of early childhood development. With regard to diagnosis, language disorders are identified when a patient has difficulty with expressive language, receptive language, or pragmatic language. Speech disorders are identified when a patients voice, fluency, or articulation call attention to the speaker because his or her speech is sufficiently different from the norm. Speech and language development should be consistent with a patients overall development and can be tracked using typical milestone markers. As speech therapy is recommended for young patients with speech delay, the primary goal of treatment is to give the patient a reliable way to exchange ideas and information in his or her daily social and educational environment. Treatment is tailored to the specific communication needs of each patient, which vary with disorder type and severity, age, and the etiology of the condition. Speech therapy is the standard of care for patients with speech delay and as this patient presents with an approximate 57% delay in speech and language skills, the requested therapy is medically necessary for this patient for 1 hour per week.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old female enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar/thoracic spine for evaluation of the enrollees left-sided pain. Findings:  The physician reviewer found that based on review of the available records, this patient has a history of prior nephrectomy for renal tumor. One provider has strongly recommended a MRI of the brain. However, it is unclear from the records provided for review whether this has been performed. The requested MRI of the thoracolumbar spine could be of use in the evaluation of the patients lower extremity pain and weakness. The patients upper extremity unilateral symptoms could also be related to cervical spine or brain abnormality. While the requested thoracolumbar MRI would not address those issues, it may be helpful in determining the etiology of the patients lower extremity issues.  In summary, this patient has a medical history of prior malignancy and extremity weakness. Satisfactory work-up should include investigation of the central nervous system. Thus, MRI of the thoracolumbar region could determine whether the patient has involvement in this area and therefore is medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 28-year-old female has requested continued residential services for treatment of her bipolar disorder, post-traumatic stress disorder, polysubstance dependence, impulse control disorder, borderline personality disorder generalized anxiety disorder and eating disorder not otherwise specified.  Findings:  The physician reviewer found that this case encompasses significant affective, anxiety and addictive influences in addition to being steeped in psychodynamic theory. It appears the patients characterological organization and family dynamics fuel a cyclical pattern of maladaptive behaviors which in turn exacerbates the psychiatric pathology. A previous independent medical review determined that residential treatment level of care was medically necessary for this patient, and the patients treatment team indicates that residential care will be complete by the date at issue. Based on the documentation provided, there is continuing evidence of persistently severe suicidality and mood symptoms, along with substance abuse and global impairment which were unresponsive to less restrictive treatment settings prior to admission. Such symptomatology is more than likely to result in undue morbidity and possible psychiatric hospitalization if the patient is discharged prematurely. Affording the patient a planned discharge on the date at issue will provide her with the best chance for success in the outpatient setting.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the positron emission tomography (PET) with computed tomography (CT) fusion and single photon emission computed tomography (SPECT) for evaluation of the enrollees confusion and memory decline.  Findings: Two physician reviewers found that the incidence of central nervous system involvement in systemic lupus erythematosus is unusual. The difficulty when one is faced with a patient with severe cognitive decline and tremors is to differentiate cerebral vasculitis associated with an autoimmune disease such as systemic lupus erythematosus versus more common etiologies such as Alzheimers disease and related entities. Traditional imaging such as CT and MRI provide only anatomical information about the brain. The PET/CT and SPECT provides physiologic information not available on conventional imaging. The use of PET allows glucose uptake of infiltrating granulocytes and tissue macrophages to be visualized and quantified to delineate the inflammatory reaction of vasculitis. Thus, the positive findings as seen in this patient with known Lupus are more likely to be associated with Lupus vasculitis rather than other non-inflammatory conditions. This differentiation is crucial for therapy. No other imaging test allows such quantification of inflammatory estimation of disease in the brain than PET/CT and SPECT. For these reasons, the PET with CT fusion and SPECT scan were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedures at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Forteo. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee who has a history of osteoporosis.Findings:  Current peer reviewed literature supports the use of Forteo for the treatment of osteoporosis following failure of first line treatment. However, current prescribing information from the manufacturer and U.S. Food and Drug Administration (FDA) does not support the use of Forteo for more than two years throughout the life of the patient based on the risk of osteosarcoma. Jeremiah and colleagues recommend first line treatment of osteoporosis which consists of fall prevention, smoking cessation, moderation of alcohol intake, and bisphosphonate therapy. Teriparatide (Forteo) is recommended as an alternative effective treatment for certain subsets of patients and for those who are unable to take or whose condition does not respond to bisphosphonates. These recommendations are supported by Levis and Theodore in their summary of comparative effectiveness review of treatment to prevent fractures in men and women with low bone density or osteoporosis. However, current Forteo prescribing information from the manufacturer and FDA guidance state that Forteo should not be taken for more than two years over the patients lifetime to mitigate the risk factors for osteosarcoma. This patient has previously used Forteo for a two year period. She sustained bilateral subtrochanteric fractures; a right femur fracture again in September, that healed on its own at that time; and bilateral femur fractures again, requiring additional surgery. Based on the provided record, there is no compelling rationale provided to support the medical necessity for the use of Forteo in this patient as an exception to the manufacturer and FDA indications. Therefore, the medical necessity for the medication Forteo for the treatment of the patients medical condition has not been established.Final Result: The reviewer has determined that 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for psychiatric intensive outpatient program (IOP) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Applying LOCUS guidelines, this patient met the criteria for psychiatric IOP services. The patient was at some risk of harm (score 2) as she exhibited passive suicidal ideation with periodic flare-ups of active suicidal ideation with intention and plan. The patient has a history of an overdose attempt necessitating critical care and psychiatric hospitalization in 2019. The patient reported that she stockpiled medications at home so she could overdose. The patient demonstrated serious functional impairment (score 4) due to ongoing significant anxiety and depression symptoms necessitating active medication management while at the IOP. The patient dropped out of college due to mental health concerns. The patient has significant comorbidities (score 3) involving trauma, anxiety, depression, and possible bipolar disorder. The patients recovery environment was moderately stressful (score 3) as she lived with her father and the provider noted that the patient had parent-child relational challenges. The patients recovery environment provided limited support (score 3) as the records document the patient had emotional distance with her family and frequent feelings of isolation. The patient has exhibited poor response to treatment (score 4) given her history of three hospitalizations and chronic suicidal ideation despite intensive therapies and medication management since age 16. The patient was constructive in treatment (score 2) as she was engaged in therapy. The records state that the patient made gradual incremental improvement with periodic setbacks. This gives the patient a composite score of 22, which is consistent with medically monitored non-residential services, such as IOP. Given this support, the psychiatric IOP services were 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 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 48-year-old female enrollee has requested a neurosurgical referral for the treatment of her migraines/chronic headaches. Findings:  The physician reviewer found that the requested neurological consultation is not medically indicated for the patients medical condition. Conservative treatment, such as medications, physical therapy and weight reduction, are successful treatment modalities for this patients condition. A neurosurgery consultation is not medically appropriate in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

A 50-year-old female enrollee has requested Synvisc injections for treatment of her osteoarthritis. Findings:  Three physician reviewers found that while Synvisc injections have been approved for osteoarthritis of the knee, there is no scientific literature supporting the use of Synvisc for hip arthrosis.  The patient does not meet the standard guidelines for Synvisc injections based on her diagnosis.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient hospitalization. Findings:  The physician reviewer found that functional impairments due to traumatically acquired brain insults improve with time, i.e., natural recovery processes.  These impairments are also amenable to rehabilitation interventions.  In this case, the patient sustained a mild TBI due to a motorcycle accident and had post-concussive symptoms.  He otherwise did not sustain other significant injuries.  He was originally intubated on account of persistent vomiting, but self-extubated.  He subsequently was eating a regular oral diet, having bowel movements and was stable medically.  There were no surgical needs.  He did have mild mobility issues, ongoing cognitive issues and decreased safety awareness.  He was seen and followed by multiple specialists.  Overall, the records support that the patient was going to need supervision for safety, but he did not otherwise have medical, surgical or other needs requiring acute inpatient hospital level care.  The trauma team was waiting for transfer to a rehabilitation facility during this period, but did not otherwise indicate need for ongoing inpatient level hospital care. The supervision that he needed could have been provided in the community by caregiver(s).  The rehabilitation team had already otherwise demonstrated independence with household level mobility.  He was also otherwise at the supervision to independent level of care for his basic self-care.  His rehabilitation needs could have been provided in the community at the outpatient level.  All told, inpatient hospitalization for the dates of service in question was not medically indicated 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for radical resection of left retroperitoneal tumor with en bloc left nephrectomy performed in one surgery. Optimal treatment of dedifferentiated liposarcoma requires radical resection. During the initial operation, it is important to attempt to remove all disease while preserving critical neurovascular structures. Researchers found that vascular involvement, positive surgical margins, and histologic grade are the key predictors of disease free survival. For this patient, surgery may include a left nephrectomy. Performance of a radical resection in one procedure with the en bloc left nephrectomy is the standard of care in this clinical setting. Therefore, the requested radical resection of left retroperitoneal tumor with en bloc left nephrectomy performed in one surgery is medically necessary for treatment of this patient. 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 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

A 41-year-old male enrollee requested authorization and coverage of Silikon 1000 injections for the treatment of facial lipodystrophy.  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 overturned the health plans denial on the basis that the requested medication is medically necessary for treatment of the patients medical condition.