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

The patient has requested authorization and coverage for five (5) sessions of acupuncture treatment. The patient has been diagnosed with low back pain. The provider noted that the patient does not participate in regular exercise or any recommended home physical therapy. Physical examination findings included no tenderness to palpation over the spine. A straight leg raise test was negative bilaterally. Strength was full and sensation was intact. The provider noted that the patient has tried and failed physical therapy and chiropractic treatment. Researchers noted that the recommendations on acupuncture have discrepancies related to its use in patients with non-specific low back pain. The medical evidence does not support the requested services in this clinical setting. Therefore, five (5) sessions of acupuncture treatment are 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 sub-specialty 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: Experimental/Investigational
Decision: Upheld

A 44-year-old female enrollee has requested for a magnetic resonance imaging (MRI) of the left breast for evaluation of her medical condition.   Findings:  Three physician reviewers found that the indications for breast MRI have been clearly defined by the American Cancer Society. These indications include a patient with a defined high risk of developing breast cancer, someone newly diagnosed with breast cancer, to evaluate extent of disease, assessment of disease after treatment, as well as several other specific indications. Although this patient has a family history of breast cancer, she does not meet the defined criteria for a breast MRI.
Appeal type: Urgent Care
Decision: Overturned

A 35-year-old male requested coverage for past emergency services.  Findings:  The physician reviewer found that the patient presented to the emergency department (ED) on the date at issue and was seen by a family nurse practitioner who recorded a chief complaint of left upper dental pain for one month and concerns regarding swelling within the patients left cheek. No pain level was recorded. The physical examination did not note any facial swelling but did note pain in tooth #13 without evidence of a local infection. The patient was afebrile. He was diagnosed with dentalgia and discharged from the ED to follow up with his dentist. The patient wrote a letter which outlined an extensive past medical history of left-sided facial infections, requiring hospitalization on two occasions, and substantiated this with letters written by multiple providers, which attested to the determination that the problem was medical, not dental.   At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date at issue. Despite the fact that the nurse practitioner failed to document a pain level and found the physical exam to be benign, in this case the patients history of previous, severe facial infections is compelling. An individual such as this patient who has had severe facial infections requiring hospitalization on two separate occasions in the past would reasonably fear a recurrence of infection and seek medical evaluation if symptoms suggested the presence or worsening of such an infection. Therefore, a prudent layperson in this patients situation would have thought this to be an emergency medical condition and would have sought immediate medical attention.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Norditropin Flexpro 15 mg/1.5 mL daily injection. Based on the Centers for Disease Control and Prevention (CDC) standards for this transgender male patient, his height tracked between the ninth and 15th percentiles, which was within normal ranges for males. The patients height was normal at the sixth percentile for transgender males, despite a low growth velocity. The available measurements support that this patient has normal stature for a male transgender. The patient does not meet the current U.S. Food and Drug Administration (FDA) approved indications for growth hormone therapy or the generally accepted diagnostic criteria for growth hormone deficiency given the normal bone age, height, and predicted adult height. The patients recently low growth velocity is likely due to malabsorption from partially uncontrolled Crohns disease, appetite suppression by Adderall XR, and/or puberty suppressed by long-acting gonadotropin releasing hormone (GnRH) agonist. All told, the requested Norditropin Flexpro 15 mg/1.5 mL daily injection is not medically necessary for 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 pediatrics with subspecialty certification in pediatric endocrinology 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 patients parent has requested authorization and coverage for Aimovig. The records provided for review document that this patient has refractory chronic migraine without aura. She has not received benefit from multiple medications from different classes including anticonvulsants and antidepressants. She has experienced significant side effects from several medications. Her provider stated that further trials of alternative medications are contraindicated. Aimovig is a calcitonin gene-related peptide (CGRP) receptor monoclonal antibody. CGRP has been found to play a primary role in the pathogenesis of migraine. Further, researchers concluded that Aimovig showed consistent efficacy in episodic migraine patients who had failed prior preventive treatments and was well tolerated across subgroups. Although there is limited data on the use of Aimovig in patients under 18 years of age, the available studies support its safety and effectiveness in patients with refractory chronic migraine without aura. Therefore, Aimovig 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 pediatrics and neurology with special qualification in child 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

A 60-year-old female enrollee has requested a standard wheelchair for treatment of her peripheral arterial disease status post above the knee amputation.  Findings:  The physician reviewer found that when properly fitted, prosthesis allow for independence with activities and mobility, even for patients with transfemoral amputations (Esquenazi; Fleury, et al). The patient in this case has been fitted for a prosthetic device and has undergone training for prosthetic gait. Overall, the medical records do not establish that her prosthesis does not currently meet her functional needs. In addition, the records do not demonstrate that a new manual wheelchair is necessary for the patient to accomplish her mobility related activities of daily living. Therefore, the requested standard wheelchair is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old female enrollee has requested supervised physical therapy and physical therapy evaluation and treatment for treatment of her pain. Findings:  The physician reviewer found that after being seen and evaluated in a pain management clinic, she was told she had myofascial pain syndrome, and an intensive reconditioning program was recommended. The patient was concerned she would not be able to tolerate the program.  As an alternative, she was referred to the clinics weekly exercise program. She declined enrollment in the program and requested a referral for additional physical therapy for lower back strengthening, flexibility, and sacroiliac joint exercises.   The patient received a course of physical therapy with limited benefit. Her health care providers determined that a supervised exercise program was the most appropriate next strategy for managing her chronic pain. The literature supports the benefits of an exercise program for the management of chronic back pain. Therefore, in the case under review, the services requested by the patient are not medically indicated.  All told, a referral for supervised physical therapy and physical therapy evaluation and treatment are not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi with ribavirin for treatment of his hepatitis C. Findings: Three physician reviewers found that the current medical evidence supports the requested medications in this clinical setting. Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, the medical evidence supports treatment of all patients with chronic hepatitis C, except those with limited life expectancy due to non-liver-related comorbid conditions. Initiation of treatment when patients have early stage disease may help avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from hepatitis C. All told, the requested medications are medically necessary for the treatment of this patient. Final Result: Three reviewers determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Overturned

An enrollee has requested authorization and coverage for Monovisc injection.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, there is a history of relief from prior injections. Therefore, Monovisc injection is medically necessary to treat the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. The patient has demonstrated moderate withdrawal. Although the patient does not have significant biomedical comorbidities, he does have an unhealthy religious preoccupation. In addition, the patient is currently on antipsychotic and mood stabilizing medications. The provider described the patient as in the preparation stage for change. The patient reported that he would stop taking medications if he is transitioned to a lower level of care. The patient remains at risk for relapse as prior to this admission, he left prior treatment against medical advice as he was feeling agitated. Once discharged, the patient returned to using substances within hours. The patients recovery environment is described as intermittently unstable. The patient requires a safe and stable living environment in order to develop his recovery skills. Thus, he qualifies for ASAM Level III treatment similar the services received at the current RTC facility. Given the severity of the patients illness, the RTC services provided 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Applying the ASAM guideline, the patient is at risk for subacute withdrawal. The patients CIWA has been positive for moderate agitation, anxiety, paroxysmal sweating and tremors. The records document that the patient is in need of medically assisted treatment. Continued substance use poses a serious risk to the patients health. Substance use disinhibits the patients existing premorbid functioning and conditions such as anger, self-harming behaviors, and aggression. Moreover, the chart indicates a history of recurrent suicidal ideation and feelings of hopelessness. The patients mental status is sufficient to permit participation. However, he has been unable to control his substance use without 24-hour support especially given his premorbid impulsivity, social isolation and withdrawal. His significant functional deficits require 24-hour staff availability for intervention. The patient has exhibited limited insight into his substance use disorder and is currently developing coping skills. He continues to require 24-hour support given his limited social support and absent coping skills. The patient does not recognize his relapse triggers and lacks insight into the benefits of care. The patients fear is a trigger and results in anger. He also tends to act out in self-destructive ways, which requires 24-hour supports to redirect him from using. The patients recovery environment is too chaotic to support his sobriety. His significant other uses substances and his adopted parents appear to be largely unaccepting of his gender choice thereby perpetuating his tendency to self-isolate and use substances as a maladaptive coping strategy. Given these findings, the 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: Upheld

The patient is a 59-year-old male with apparently a long history of mood disorder treated with various medications as well as dietary supplements. He also reportedly had experienced several falls for 18 months prior to a SPECT scan being ordered, ostensibly to evaluate possible brain trauma. Apparently, prior to the SPECT scan the patient also had a head MRI that was noted to be normal. The Health Plan has denied coverage for the SPECT scan at issue on the basis it was not medically necessary for evaluation of the patients condition. Upon review of the relevant medical literature and the submitted medical records, a SPECT scan was not medically necessary to diagnose or manage the patients condition. The patient reports none of his falls resulted in loss of consciousness or required medical evaluation or treatment. Additionally, there is no indication the patient had his vision evaluated. Furthermore, findings of the SPECT scan did not contribute to the diagnosis or treatment of the patients depressive symptomatology. Therefore, I have determined that the SPECT scan at issue was not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 34-year-old male with a body mass index (BMI) of 48. Based on the submitted information, it appears the patient has undergone a psychological evaluation and has been found to be an appropriate candidate for weight loss surgery. The patient has requested authorization and coverage for gastric bypass surgery. The Health Plan indicates the requested procedure is not medically necessary for treatment of the patients medical condition.With a BMI of 48 the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Three reviewers found that this technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. Accordingly, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the diagnostic procedure at issue was 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 board certified in diagnostic radiology and are actively practicing. All three 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 Repatha SureClick subcutaneous solution auto-injector 140 mg/mL.Findings: The submitted documentation does not support the medical necessity of the requested medication. This patient has documented cardiovascular disease and a recent LDL that is already close to a goal of less than 70 mg/dl while on atorvastatin 40 mg per day.  Repatha is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol despite maximum tolerated medication. In this case, the documentation does not support the patient has heterozygous familial hypercholesterolemia, and it would be reasonable to expect that a higher dose statin medication (atorvastatin 80 mg or rosuvastatin 40 mg) may bring the patients LDL to within a goal of less than 70 mg/dl.  Moreover, the records do not document a trial of adding ezetimibe, which has been shown to be safe and effective at further lowering LDL cholesterol when used with statin medication. Therefore, the requested Repatha SureClick subcutaneous solution auto-injection 140 mg/mL is not medically necessary 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.