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

An enrollee has requested authorization and coverage for anterior cervical discectomy with fusion sooner than presently scheduled by the provider (2+ months). In this case, the patient presents with complaints of worsening neck pain radiating into the bilateral upper extremities. The patients reported signs and symptoms are consistent with possible cervical myelopathy and correlate with imaging findings of C5/6 disc and osteophyte complex protrusions indenting the spinal cord with possible cord signal change. The patient has reportedly failed conservative treatment, and he has been recommended for C5/6 anterior cervical discectomy and fusion, which is apparently scheduled for a date that is 2+ months distant. He is requesting an earlier surgical date. Records document that he has been placed on the surgical scheduling list as a high priority. However, surgeries were being scheduled based on medical necessity and pandemic reopening guidelines. Records reflect that the patient has been advised to present to the emergency department for any new or worsening neurologic symptoms. There is no indication that the patient has emergent indications at this time to support an earlier surgical date. Under these circumstances, a surgical date for an anterior cervical discectomy with fusion earlier than presently scheduled is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that requested scheduling of services is 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 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: Upheld

The patient is a 12-year-old female with advanced sexual development who was projected to have short adult height. According to a note from a pediatric endocrinologist dated October 2005, when the patient was 410 at 11 years and 10 months she was to be given both Lupron Depot injections and growth hormone. The provider comments however in this note that Unfortunately the growth hormone has not been very beneficial. She is considering using Humatrope. I dont really believe that there will be a significant difference between the two medications. He also comments that a recent bone age was 13 years and that the patient will likely not attain a height of 5 without immediate action. The mid-parental height target was 53.5. There is a cousin who had early puberty and became a 510 adult. A note from another endocrinologist dated May 2005 indicated that the patient had a normal rate of growth at the 25th percentile for height albeit she had been at the 50th percentile earlier in her life. She began breast development at 10 years and 1 month and at this examination she had progressed to Tanner 3 breasts and Tanner stage 4 pubic hair. The predicted adult height was 51, which is the mothers height. This endocrinologist did not recommend growth hormone therapy. Normal growth hormone levels were given which appear to be in response to a stimulation procedure. There was no IGF-1 level documented. A bone age report from September 2005 indicates a reading of 11 years (though the number of months is not legible) while one from May 2005 estimated the bone age to be 12 years. A note from a pediatrician dated September 2005 indicated that the patient had a height of 410.75. She had apparently grown 3.5 cm on growth hormone and was back to the 50th percentile.At issue is whether growth hormone therapy was/is medically necessary for treatment of the patients medical condition.Review of the records provided demonstrates the patients reported bone ages are confusingly inconsistent with each other. On balance, it does seem likely that the patient will have an adult height approaching that of her mother. The patient has a normal rate of growth, she does not have growth hormone deficiency and she does not meet the Food and Drug Administration criteria for use of growth hormone in idiopathic short stature. The use of Lupron Depot to attempt to prolong her growth period appears reasonable and should be supported until epiphyseal closure.  Based upon the information set forth above, I have determined the therapy at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the computed tomography (CT) scan provided on 9/12/17 for evaluation of the enrollees back pain. Findings:  The physician reviewer found that This patient had symptoms which were suspicious of a compression fracture in the mid thoracic spine, possibly on the basis of insufficiency. There were positive radiographic findings on plain film imaging. Given these findings and the clinical symptomatology, further evaluation by computed tomography (CT) was indicated in order to assess the nature of the possible compression fracture and if present, whether the fracture involved the posterior column of the spine, which would have revealed an unstable fracture. Such determinations are not possible on plain x-rays and cross-sectional imaging. For these reason, in this case, the CT scan provided was medically necessary for further evaluation of this patients medical condition. Final Result: The reviewer determined that the diagnostic procedure at issue was medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 reimbursement for inpatient psychiatric hospitalization services. Findings:  The physician reviewer found that due to the persistent affective symptom complex with disordered thought processing and violent behavior in context of autism spectrum disorder, a conservative psychiatric hospital stay was to be expected. Thus, the inpatient services provided in this case were reasonably expected to improve the patients condition and prevent a more serious episode of illness. Bipolar disorder is a chronic and debilitating mental illness. It is associated with poor clinical outcomes and erratic behaviors. The patient had been on a downward trend since late 2015. He was hospitalized earlier in 2016 and was not responding to outpatient treatment services. Upon presentation, the patient was violent, delusional and hypomanic. Although not suicidal, he was determined to be gravely disabled and a potential risk to others. During the admission, nursing notes described this patient as anxious, irritable and depressed and irritable with a flat affect . The patient was noted to be labile and focused on discharge , aggressive with a restricted affect , and disorganized, labile, and irritable. The psychiatrists documentation noted ongoing grandiosity, delusional thinking and abysmal insight with no means to support himself. His family was supportive but not sympathetic to the patients unrealistic plans while his receptiveness to aftercare plans changed frequently. During the course of the admission, the patient was engaged in active treatment consistent with evidence-based practice. He participated in group and milieu therapies, and received individual services as well. His medication regimen was optimized. The patients family was involved throughout the course of the hospitalization.  His delusional complex was clearing. He was able to interact appropriately with his father and brother. Retaining the patient on the unit to consolidate these gains and solidify an aftercare plan was consistent with good psychiatric practice and more than likely reduced the likelihood of prompt re-admission. 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: Experimental/Investigational
Decision: Overturned

The parent of a 19-year-old male enrollee has requested irritable bowel disease serology marker testing for an evaluation of the enrollees abdominal complaints. Findings:  Two physician reviewers found that the patient has a history of abdominal complaints consisting of pain with a change in bowel habits over a 10 to 12 month period. He did not have any alarm symptoms that would have prompted a colonoscopy at the time, and a decision to order an IBD serology was made. When the IBD serology came back positive, a colonoscopy was performed. The colonoscopy revealed aphtoid ulcerations in the patients left and right colon extending into the terminal ileum with a serpiginous ulcer seen there. Biopsies of these lesions showed some cryptitis, but were not diagnostic of IBD. Putting together the symptoms, endoscopic findings and the serology have helped confirmed the patients diagnosis. Although not performed in the traditional order of a colonoscopy preceding the IBD serology, in this case, an IBD serology would not only have been helpful to confirm the diagnosis, but also led the gastroenterologist to the right test, i.e. the colonoscopy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epidiolex 100 mg/mL solution. Cannabidiol was reported to improve psychosis in patients with schizophrenia in two randomized controlled clinical trials (McGuire, et al.; Black, et al.). However, there is a paucity of data demonstrating that cannabidiol is effective in the treatment of patients with bipolar disorder. This patients records support a diagnosis of bipolar disorder. In addition, there are well established algorithms for to direct the treatment of bipolar mania, which currently do not recommend the use of cannabidiol in for bipolar mania or anxiety (Stovall, et al.). Moreover, the medical literature does not recommend the use of cannabidiol for bipolar mania or anxiety due to the lack of evidence (Black, et al.). In this clinical setting, the requested Epidiolex is not likely to provide this patient with a superior health outcome when compared to treatment with conventional options. All told, the requested Epidiolex 100 mg/mL solution is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the Epidiolex 100 mg/mL solution is not likely to be more beneficial for treatment of the patient's medical condition than any available standard therapy. Final Result: The reviewers determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in psychiatry 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

The patient is a 14-year-old female with an initial diagnosis of primary hypothyroidism at the age of 12, though symptoms of hypothyroidism were apparently present by history since the age of 8. Her height in April 2003 was already significantly below 2.S.D. Biochemical findings supported a severe hypothyroid state with T4 level <2.0 and a TSH of 697. A request has been made for authorization and coverage of growth hormone therapy. The Health Plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the patients condition.The patients diagnosis of hypothyroidism is sufficient to explain her short stature at presentation. In this case, a diagnosis of idiopathic short stature is not appropriate or indicated. Although most of this height deficit may be recovered with adequate therapy the patients thyroid function has remained poorly controlled, partly from non-compliance. Further, the unfortunate yet age appropriate onset of the patients pubertal development additionally limits the patients ability or time to recover the hypothyroidism-induced height deficit.Although success outcomes remain controversial, treatment with Lupron to retard pubertal maturation is medically indicated in patients such as this patient. However, there are no consistent evidence-based studies confirming that the addition of growth hormone in this particular setting is beneficial in increasing height potential. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 69-year-old female enrollee has requested breast magnetic resonance imaging (MRI) for evaluation of her medical condition. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested diagnostic procedure.  The current medical evidence supports the requested breast MRI in this clinical setting.  The patient is of Ashkenazi Jewish descent, which is a known increased risk factor for breast cancer.  The records note a family history of breast cancer in the patients sister, as well as breast malignancy in three first cousins, one of whom died of breast cancer at age 35.  Although the records indicate that the patients sister is reportedly BRCA negative, the records do not indicate that the patient was tested for BRCA genetic mutation.  All told, the requested breast MRI is medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for Xeljanz tablets. This patient is six-years-old with a history of alopecia areata that has progressed to alopecia totalis, which involves the scalp as well as the eyebrows and eyelashes. Initially, he was not bothered by the disease process, but once his peers began to tease him, it affected his mood. Per review of the available medical records, he became more irritable and demonstrated behavioral problems due to his hair loss. Since starting on the Xeljanz about one year ago, he has shown a positive response and he has been tolerating it well. Prior treatment has included several first- and second-line treatments without significant improvement. Medical literature reported that the recommended first-line therapy for young patients is topical steroids. This patient has not responded to topical steroid therapy as well as methotrexate and Plaquenil, which are considered second-line therapies. Given these findings, the requested Xeljanz tablets are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Xeljanz tablets are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in dermatology 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: The patient has requested authorization and coverage for oxycodone. The Centers for Disease Control and Prevention (CDC) guidelines state that, Clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. The Federation of State Medical Boards (FSMB) guidelines reported that, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. Based on the CDC and FSMB guidelines, this patients records do not document a current indication for treatment with oxycodone. The patients is noted to have peripheral neuropathy and chronic low back pain, which was being treated with oxycodone, gabapentin, and Flexeril. However, there is a lack of evidence that the benefits outweigh the potential harms to support continued oxycodone treatment in this clinical setting. The patient reportedly tested positive for methamphetamines on a urine drug screen in September of 2020 and he has a previous history of substance use disorder involving methamphetamines and cocaine. Thus, the patient is not considered a good candidate for opioid therapy. Moreover, the patients records do not demonstrate that the patient has exhausted non-opioid treatment options. Given these findings, the requested oxycodone is not 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 upheld. Credentials/Qualifications: The reviewer board certified in anesthesiology with subspecialty certification in pain management 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 20-year-old female enrollee has requested acute psychiatric inpatient residential care services for treatment of her behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, this patients level of functioning is extremely impaired as evidenced by lethargy and only partial orientation. Her delusions regarding food put her at risk for starvation, while her mood is depressed with suicidal ideation. The providers note that the patient has disorganized thoughts, behavior, catatonia and delusions, which are the hallmarks of psychosis. She does not currently have the capacity to make medical decisions regarding her psychiatric care and her statements that she wants to leave the hospital should be considered within the context of her psychosis and limited insight. Acute inpatient residential care services are appropriate to treat the patients condition as she cannot be safely and effectively treated in a less restrictive treatment setting. Therefore, the acute psychiatric inpatient residential care services provided from the date in question and forward are medically necessary for this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested acute inpatient hospital services for treatment of his medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient was hospitalized for the treatment of multiple injuries.  He underwent surgical fixation of fractures and treatment of multiple lacerations.  He remained stable during the period of care at issue.  The documentation supports that he was stable with normal vital signs and without complications.  He was tolerating an oral diet, voiding and ambulating.  The patient could have been safely treated at a lower level of care.  All told, acute inpatient hospital services on the dates in question were 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 reviewer is board certified in internal 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

A 25-year-old female enrollee has requested for resumption of acute rehabilitation therapy for treatment of her status-post stroke. Findings:  The physician reviewer found that the peer reviewed medical literature indicates that patient outcomes are dependent upon the severity of the stroke rather than the location or degree of continued therapy. Therefore, the intensity or location of future rehabilitation therapy is not likely to influence the patients rate of brain recovery after the initial acute stroke period.