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

A 45-year-old female enrollee requested authorization and coverage of the prescription medication Xenical for the treatment of morbid obesity.  The health plan denied the enrollees request indicating the requested medication in not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested Xenical is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 57-year-old male with depression and migraine headaches. He reports a recent weight gain of 30 pounds. The patients medical therapy includes, Cymbalta, Wellbutrin, lithium, Ritalin, Neurontin, Propecia, Provigil, Xenical, Ativan, Zyprexa and Ambien. He would like to lose the weight he has gained, and has reportedly had good results with Xenical in the past.  The patients request for authorization of Xenical was denied by the Health Plan based upon a determination that the medication is not medically necessary.There is no medical indication for Xenical therapy at this time. The record does not suggest that the patient has failed to lose weight with dietary management or a simple exercise program. He stated that he could not participate in an exercise program, but did not fully explain why or describe unsuccessful dietary changes he had made. The record does not provide the patients body mass index (BMI) or document co-morbidities such as medically treated hypertension, diabetes, coronary artery disease, dyslipidemia, cerebral vascular accident, sleep apnea required CPAP, or degenerative joint disease.  The patient is taking multiple medications that have weight gain as a side effect (primarily Zyprexa), but it does not appear from the record that his health status would preclude the more traditional methods of weight loss.  Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 24-year-old female enrollee requested finger joint manipulation under anesthesia for medical treatment of her medical condition.  Findings:  Two physician reviewers found that this patient was diagnosed with small flexor tenosynovitis. The usual progression of treatment includes treating with NSAIDs, rest and bracing, followed by physical therapy or occupational therapy.  More acute cases are treated with corticosteroid injections.  The current medical evidence has not established the superior efficacy of the services at issue.  There is a lack of support for the use of manipulation under anesthesia to break up the scar tissue in this clinical setting.  There is a paucity of medical studies demonstrating that this treatment is helpful for joints such as fingers.  Therefore, the superior effectiveness of finger joint manipulation under anesthesia has not been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for residential treatment for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient presented to her provider reporting depression and anxiety.  However, her insight, judgment, and impulse control were all good on mental status examination.  The patient was aware of her deficits and indicated that she could grow up more.  She denied suicidal or homicidal ideation, she was not manic or psychotic, and she was not gravely disabled.  While she did endorse being under a great deal of stress due to finances and poor grades at school, these are not reasons for residential level of care. The records indicate that she was medically stable. She was an active participant in her groups, and she was being seen in individual and medication management appointments.  Final Result: The reviewers 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 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

A 47-year-old male enrollee has requested a 24-hour ambulatory blood pressure monitor for an evaluation of his hypertension. Findings:  Two physician reviewers found that ABPM provides a large number of measurements over time (usually 24 hours), which can be plotted to give a profile of blood pressure. Although in practice the average daytime blood pressure is used to govern decisions, the clinical use of ABPM has allowed a number of phenomena in hypertension to be identified that would otherwise not have been. ABPM is of benefit in excluding white coat hypertension and in helping establish the diagnosis of patients with borderline hypertension. In terms of white coat hypertension, patients with normal blood pressure may have higher daytime ambulatory pressures than blood pressure measured conventionally. But in those with hypertension, daytime blood pressure is usually substantially, but unpredictably lower than blood pressure measured conventionally. For patients whose blood pressures are borderline, they may benefit from ABPM by avoiding drug therapy, and in establishing the diagnosis of hypertension.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 48-year-old woman with a longstanding history of back pain following a motor vehicle accident. The patient also reports neck, arm, and hand pain. The patient reports that she has benefited from physical therapy in the past. She has requested authorization for continued physical therapy. The Health Plan has denied the patients request.The submitted documentation indicates the patient has received 20 visits of physical therapy. Review of the provided notes demonstrates that the patients condition has reached a plateau with therapy. The patients condition is chronic and is not likely to improve with continued physical therapy. Other options should be considered including additional work-up to determine the etiology of her numbness. Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 50-year-old male enrollee has requested anastrozole (Arimidex) for treatment of his gynecomastia. Findings:  Three physician reviewers found that Arimidex is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. There is no indication that the patient has symptomatic gynecomastia. In addition, the records suggest the patients high estrogen levels are likely a result of excessive alcohol intake, testosterone therapy, and obesity, all of which contribute to increased conversion of testosterone into estrogen. Arimidex has not been approved for this indication. Most studies using Arimidex in men are related to the treatment of pubertal gynecomastia or patients receiving therapy for prostate cancer (Plourde, et al). High estradiol levels are usually not treated unless it causes symptomatic gynecomastia. In the absence of documentation that this patient has recent onset tender gynecomastia, treatment with an anti-estrogen therapy such as tamoxifen is likely to be more beneficial than the use of Arimidex.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for partial hospitalization program (PHP) treatment level of care services provided for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that based on the documentation submitted for review, the PHP treatment level of care services provided was medically necessary for treatment of the patients medical condition. During the dates in dispute, the patient had recurrence of symptoms that included anxiety, panic, paranoia and psychosis. Continued treatment at the PHP level of care was medically indicated due to the degree of the patients symptoms. 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: Experimental/Investigational
Decision: Overturned

A 35-year-old male has requested magnetoencephalography (MEG) for evaluation of seizure disorder.  Findings:  Two physician reviewers found that although evidence from large scale, placebo-controlled, clinical trials is limited, there are several smaller studies and case series showing the usefulness of MEG. Over the past decade, MEG has been increasingly utilized for presurgical localization of epileptiform discharges, presurgical localization of the sensorimotor or visual cortex and preoperative planning to guide the placement of a grid for epilepsy surgery. Compared with other modalities of epilepsy mapping, MEG provides the best temporal and spatial resolutions, without the invasiveness. MEG is no longer considered experimental and is essential for the presurgical evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: This patient is a 61-year-old female diagnosed with post-menopausal osteoporosis w/o fracture. Findings:  The physician reviewer found that a dual-energy x-ray absorptiometry (DEXA) scan obtained showed a left hip T score of -1.4 and a spine T score of -2.5. An x-ray of the left hip performed revealed moderate left hip osteoarthritis and less severe osteoarthritis of the right hip. Laboratory results showed normal creatinine levels and kidney function. The patient has been treated with physical therapy, Citracal, and vitamin D. Actonel was discontinued in January 2019 due to heartburn. Physical examination findings  included limited range of motion in the left hip. The patient has requested reimbursement and prospective coverage for denosumab (Prolia) that was provided very six months. The Health Plan denied the request and reproted the Prolia was not and is not medically necessary for the treatment of this patient. At issue in this case is whether Prolia that was administered and forward, every six months was and/or is medically necessary for treatment of the patients medical condition. The patients fracture risk assessment tool (FRAX) score indicates a 10-year risk of fracture. Management of postmenopausal osteoporosis includes bisphosphonates, which are considered first-line treatment. The patient reported heartburn while taking an oral bisphosphate. Guidelines recommend intravenous bisphosphonates when oral bisphosphonates cannot be tolerated Prolia may cause hypocalcemia, serious skin infections, skin rash or osteonecrosis of the jaw and atypical femur fractures. Data suggests that when Prolia treatment is stopped, bone loss can be rapid As this patient has normal kidney function and is not at high risk for fracture, intravenous bisphosphonates are the preferred agents for treatment. Therefore, the Prolia that was received on 2/9/19 and forward, every six months, was not and 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 allergy and immunology and internal medicine with a 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

A 64-year-old male enrollee has requested a 12-week course of Sovaldi 400mg for treatment of his hepatitis C. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  The current medical evidence supports the requested medication in this clinical setting.  Sovaldi has been included in nationally-accepted joint treatment guidelines of the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America (AASLD/IDSA).  This patient has no contraindications to interferon-based treatment and is motivated to begin therapy before his liver disease progresses.  Allowing the patient to develop advanced fibrosis before the proposed treatment regimen will substantially reduce the efficacy of the proposed drug treatment and lower the patients chance of virologic response.  All told, the requested 12-week course of Sovaldi 400mg is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 29-year-old female enrollee has requested a percutaneous intradiscal electrothermal (IDET) procedure for the treatment of her back pain. Findings:  Three physician reviewers found that there is a lack of well-documented evidence from well-designed studies to confirm the safety, efficacy, and long-term results for IDET. It is experimental at this time and unsupported by clear scientific data. Furthermore, there are other standard treatments available to this patient that are likely to be more beneficial than IDET.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested for a liver CT scan for evaluation of her liver lesions. Findings:  The physician reviewer found that the patient remains asymptomatic and her laboratory studies are also unremarkable. Based upon the patients history and the fact that she is currently asymptomatic, there is no medical indication or need for a repeat CT scan at this time.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Nuedexta 20/10 mg.Findings:  Two of the three physician reviewers found that this patient has been diagnosed with pseudobulbar affect secondary to Parkinsons disease. Pseudobulbar affect is a condition of contextually inappropriate emotional expression that often occurs in adults with neurological damage conditions, such as amyotrophic lateral sclerosis, multiple sclerosis, stroke, traumatic brain injury, Alzheimers disease, or Parkinsons disease. Nuedexta has been approved by the U.S. Food and Drug Administration for the treatment of pseudobulbar affect. This medication has been shown to reduce the rate of pseudobulbar affect episodes and improve pseudobulbar affect severity. This medication is generally well-tolerated. The current evidence indicates that Nuedexta is a useful option for the treatment of adults with pseudobulbar affect. Thus, Nuedexta 20/10 mg is likely to be more efficacious than other treatment options. 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 neurology 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient hospital stay services. Findings:  The physician reviewer found that the documented high risk of sudden death in patients with severe left ventricular dysfunction has led to the recommendation of implantable cardioverter-defibrillators in this group of patients (Kutyifa, et al.; Klein, et al.). Current data from multiple trials support the use of a wearable cardioverter defibrillator after an initial diagnosis of severe left ventricular dysfunction with an ejection fraction less than or equal to 35%, along with guideline directed medical therapy. This patients ejection fraction was 25% per echocardiogram. Per the American College of Cardiology (ACC) and American Heart Association (AHA) guidelines, the approved and recommended timing of placement of a LifeVest wearable cardioverter defibrillator is within 40 days of an acute myocardial infarction or within 90 days of an initial diagnosis of congestive heart failure with severely reduced ejection fraction. This patients provider recommended a LifeVest early after the initial diagnosis by echocardiogram. In this clinical setting, it was reasonable to keep the patient hospitalized on a cardiac monitor maintaining surveillance for severe ventricular arrhythmias while the arrangements were made for a LifeVest wearable cardioverter defibrillator. The patient was noted to have an episode of non-sustained ventricular tachycardia. The risk of life threatening ventricular arrhythmia given the patients very low ejection fraction supports the medical necessity of the inpatient stay while awaiting the LifeVest. For these reasons, the inpatient hospital stay services provided from 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 internal medicine with subspecialty certification in cardiology 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 massage therapy for (1) one-hour sessions twice a week, (2) a one-hour session once a week, (3) 30-minute sessions twice a week, or (4) a 30-minute session once a week. Findings:  The physician reviewer found that Chronic benign musculoskeletal pains affecting the neck and back attributed to strain injuries may be managed using pharmacological agents, rehabilitation, psychological treatment, complementary/alternative medicine and invasive approaches. Urits and colleagues note that the aim of rehabilitation in chronic back pain patients is to reduce pain, reduce impairment and/or disability, and improve the quality of life. Chou and colleagues report nonpharmacologic therapies for low back pain include exercise, psychological therapies, multidisciplinary rehabilitation, spinal manipulation, massage, and acupuncture. Current medical literature does not establish the benefit of formal passive modalities, such as massage therapy, for non-specific low back pain. Farber and Wieland report very little confidence that massage is an effective treatment for low back pain, noting that massage resulted only in short-term improvements in acute, sub-acute, and chronic low back pain. Cohen and Hooten note that among complementary and alternative treatments, the strongest evidence in the management of chronic neck pain is for exercise, with weaker evidence supporting massage, acupuncture, yoga, and spinal manipulation in different contexts. In this case, the patient has chronic neck and back pain. The records do not document any impairments that would preclude the patient from performing an appropriate independent exercise program, including stretching and strengthening, as well as independent soft-tissue and palliative interventions, such as self-massage using foam rollers or massage balls, and topical treatments such as ice or heat. Given that there is no expectation of a marginally significant difference in clinical course or outcomes with the requested massage therapy over an appropriate independent program, the requested services are not medically indicated. Therefore, massage therapy for (1) one-hour sessions twice a week, (2) a one-hour session once a week, (3) 30-minute sessions twice a week, or (4) a 30-minute session once a week 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case SummaryAn enrollee has requested authorization and coverage for an epidural steroid shot #2 (a second epidural steroid injection). Findings:  The physician reviewer found that The submitted documentation does not support the medical necessity of the requested service. Vorobeychik and colleagues have noted that epidural steroid injection (ESI) has shown short term improvement for radicular pain, but for no other types of low back pain. Rivera has also noted that there was moderate evidence of short term benefit of radiculopathy by ESI. ESI is supported when radiculopathy is documented with objective findings on examination. Repeat ESI injection is supported when there is at least 50% reduction in pain for a duration of 2-4weeks. In this case, the medical records provided for review do not document physical exam findings consistent with radiculopathy. Furthermore, while the records quantify the duration or degree of relief from a previous ESI, they note only one day of reduction in pain. Under these circumstances, an epidural steroid shot #2 (a second epidural steroid injection) is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology, with 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.