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

A 38-year-old female enrollee has requested Lexapro for the treatment of her depression. Findings:  The physician reviewer found that the documentation provided is sparse in terms of descriptive details about the extent of the patients depressive illness. Specifically, there is no time course, mental status examination or exact diagnosis.  It is unclear how long the patient received the Celexa. All told, there is a lack of documentation by which one could properly conclude that the patient failed Celexa and was in need of another antidepressant.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested uroplasty (percutaneous tibial nerve stimulation) for the treatment of her medical condition.  Findings:  Two physician reviewers found that there is evidence in the peer-reviewed literature from randomized trials and prospective observational trials supporting the clinical utility and impact on patient management of percutaneous tibial nerve stimulation in patients with urinary urgency and frequency.  However, most trials have a small number of patients with short term follow-up.  The current guidelines recommended behavioral therapies as a first-line of therapy for patients with overactive bladder. Behavioral therapies may be combined with pharmacologic management. Clinicians should offer oral antimuscarinics or oral 3-adrenoceptor agonists as a second-line therapy.  Percutaneous tibial nerve stimulation is recommended as a third-line therapy.  In this patients case, there are alternative treatments such as Botox injections and sacral neuromodulation.  Per the medical evidence, Botox injection is a standard third-line therapy and graded better.  All told, the services at issue were not likely to have been superior over other treatment options. Final Result: Two reviewers determined that the services at issue were 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:   All three reviewers are board certified in urology 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 surgery on the hand for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The likelihood of improvement of small finger proximal interphalangeal (PIP) joint contractures with any treatment is guarded at best.  A study by researchers found that using night progressive static and daily dynamic orthoses as an exclusive treatment during the proliferative phase led to significant improvements in the PIP joint active extension.  According to other researchers, static progressive and dynamic splints are considered effective non-operative interventions to treat stiff fingers.  The patient will be best served with static and dynamic splinting.  All told, the requested surgery on the hand is not medically indicated 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 plastic surgery with sub-specialty certification in surgery of the hand 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: A 47-year-old female enrollee has requested authorization and coverage for a 30 day residential treatment center services. The records provided for review do not support the medical necessity of 30 day RTC services for treatment of this patients medical condition. The patient is not a danger to herself or others and she is not in withdrawals or at imminent risk. She was placed on an outpatient detoxification protocol with Topamax and Librium. There have been no emotional, behavioral, or cognitive factors which suggest the need for substance abuse RTC level of care. She is medically and psychiatrically stable. She is not manic or psychotic, and she has not shown any highly impulsive or risk-taking behavior requiring the restrictive setting of RTC. Her detoxification protocol does not require an inpatient setting. She previously did well in a day treatment program and was able to maintain sobriety. There is no evidence to show that her home environment is unstable, unsafe, or not supportive. She can be safely treated at an ambulatory level of care with the additional support of community services in the 12 step groups with Alcoholics Anonymous. Thus, the requested 30 day RTC services are not medically necessary. 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 psychiatry with sub-specialty certification 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for diabetes prevention program. Type 2 diabetes mellitus is a common chronic metabolic condition. Before receiving this diagnosis, patients typically experience a long period of prediabetes. There is adequate evidence that type 2 diabetes mellitus can often be prevented or delayed by means of lifestyle interventions, medications, or metabolic surgery (Shubrook, et al.). Clinical trials have reported that patient education can help improve clinical, lifestyle, and psychosocial outcomes. Coppola and colleagues noted that, The management of type 2 diabetes mellitus includes ability and empowerment of the patient to change lifestyle, maintain an adequate diet and physical activity, manage the disease, and follow a specific program of periodic medical checks and education sessions. The authors concluded that, To obtain these goals, therapeutic patient education (TPE) is now considered a crucial element not only in the treatment but also in the prevention of type 2 diabetes. However, this patients records do not include an indication for the requested diabetes prevention program. The provider noted that the patients glucose was 81 mg/dL six months prior, with a target reference range of 60-159 mg/dL. Therefore, the requested diabetes prevention program is not medically necessary for 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 internal medicine with subspecialty certification in endocrinology, diabetes, and metabolism 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 parent of a 17-year-old male enrollee has requested reimbursement for emergency services provided at Janzen and Janzen Chiropractic from 3/13/18 through 5/18/18.  Findings:  The physician reviewer found that The submitted documentation does not support the medical necessity of the requested custom foot orthotics. The records provided for review document diagnoses of plantar fasciitis of right, left foot with associated heel spur syndrome/infracalcaneal bursitis and gastrocnemius equinus contracture.  The recommendation is for conservative treatment, which consists of over the counter (OTC) inserts, strappings, icing, and stretching exercises, non-steroidal anti-inflammatory drugs (NSAIDs), injection therapy, and rest. Final Result: The reviewer determined that the requested custom foot orthotics are not medically necessary for treatment of this patients medical condition.  Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified chiropractor and with specialization in oriental medicine and 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 43-year-old female enrollee has requested a Meniett device for the treatment of her Menieres disease. Findings:  The physician reviewer found that the nature of Menieres disease, with a highly variable clinical presentation, lack of pattern or often a provoking reason for the attacks, makes management difficult. The pathology is understood as an increase in pressure in the fluids of the inner ear, but the cause of that pressure increase in unknown. The Meniett device invokes a theory that by increasing air pressure in the middle ear, fluid in the inner ear will be displaced and Menieres symptoms will reduce. While a few early studies showed some benefit in the treated groups in reduction of dizziness, objective criteria, such as the hearing loss that accompanies Menieres disease, remain unimproved. In the case of this patient, based on the most recent treatment notes provided her symptoms are dominated by tinnitus. A review of the literature shows no evidence that the Meniett device is successful in reducing tinnitus. The patient also suffers from headaches which have been diagnosed as migraines, which may be a contributing factor in the dizzy spells. All told, there is insufficient evidence to support the use of a Meniett device is this setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment care. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. In this case, substance use dominated the patients daily routine while he had tried and failed an array of therapeutic interventions. One day prior to the disputed timeframe, the patient had significant craving and dreams of substance use. He was depressed and evasive, and had poor insight. Two days later, the patient was prescribed, but did not take, an anti-craving medication, Naltrexone.  Later that day, he met with a psychiatrist. There was concern for social anxiety, but the patient was diagnosed with unspecified depressive disorder. The provider recommended duloxetine, but the patient declined the trial. However, gabapentin was increased. It was noted that the patient was doing well in the program but was struggling with post-acute withdrawal apathy, cravings and low frustration tolerance.  Essentially, he had yet to consolidate the issues that prompted the residential placement in the first place. Thereafter, the patient remained actively engaged in treatment, including family programming and aftercare planning. The services and setting were safe, appropriate and consistent with good practice. Additionally, the services provided were reasonably expected to improve his condition and prevent a more serious episode of illness, while the duration of care was consistent with community standards. In sum, residential treatment 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her risk for breast cancer.  Findings: Two physician reviewers found that the addition of digital breast tomosynthesis reduces false positives and increases cancer detection when compared to two dimensional full field digital mammography alone. The additional three dimensional imaging allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue, offers increased cancer detection, and allows better characterization of possible masses, spiculation, and architectural distortion. In this patients case, a routine screening mammogram detected a mass and she was called back for further imaging. Thus, in this clinical setting, the use of the digital breast tomosynthesis studies 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 reviewers are board 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of her behavioral health condition. The physician reviewer found that TMS is approved by the U.S. Food and Drug Administration (FDA) for the treatment of adult patients with major depressive disorder who have failed to receive satisfactory improvement from one prior antidepressant medication at or above the minimal effective dose and duration in the current episode. The American Psychiatric Association (APA) has endorsed TMS for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial. The specific age range defining an adult is commonly assumed to be 18 years of age unless otherwise stated. This assumption is by the National Institute of Mental Health which reported, In 2013, there were an estimated 10 million adults aged 18 or older in the U.S. with [serious mental illness] SMI, In this case, the patient presents with chronic affective illness and has pursued standard therapies used to combat depression. TMS is approved for the adult population, and has evidence of utility and safety for patients 18 years of age and older.  Considering the medical records submitted for review, endorsement from the APA and the peer-reviewed literature, TMS represents a safe, appropriate treatment consistent with good medical practice that is reasonably expected to improve the patients condition and prevent a more serious episode of illness. As such, the requested therapy is medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested therapy 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 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:  An enrollee has requested authorization and coverage for an additional two (2) units of sedation.Considering that deep sedation requires titration of medications, monitoring of vital, and postoperative observation, 30 minutes of sedation time are not enough, making the additional 30 minutes of sedation medically necessary in order to carry out the procedure and allow for the patient to not undergo stress during the procedure. Anxiety is a known trigger for asthmatic patients. Ogle and Hertz state, Sedation offers a method of alleviating the fear, and for some it is the only way they will have their dental needs treated. Moreover, the authors noted, Oral sedation with benzodiazepines and anxiolysis with nitrous oxide are two effective methods to help alleviate anxiety and fear of dental procedures. For patients who are susceptible to complications from anxiety, anxiolysis and anesthesia for the entire duration of the procedure may be necessary. In this case, the patient presented with four impacted wisdom teeth, which is complicated by asthma. Considering the extent of hard and soft tissue impaction, the proximity to the inferior alveolar nerve and the maxillary sinuses, all of the third molars are complicated extractions, which will require time for their safe and efficacious removal. As such, time for the procedure and thus time for the sedation are necessary beyond a total time of 30 minutes. In this setting, one hour is a common amount of time required to carry out all of the therapy. Therefore, the requested additional two (2) units of sedation are medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested services 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 dentistry 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 pantoprazole 40 mg tablets. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether pantoprazole 40 mg tablets are medically necessary for the treatment of the patients medical condition.Studies show PPIs are effective for the treatment of gastric erosions and ulcers. Despite concerns regarding the long-term safety of PPIs, the risk-benefit profiles strongly favor the use of PPIs in select patients. A PPI is recommended for patients that fail therapy or are Helicobacter pylori negative. In this case, the patient endorsed abdominal pain and was found to have gastric erosions during endoscopy. The medical evidence supports the requested medication in this clinical setting. Therefore, pantoprazole 40 mg tablets are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology 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 49-year-old male enrollee has requested Lyrica (pregabalin) for the treatment of his neck pain. Findings:  The physician reviewer found that Lyrica (pregabalin) is an anticonvulsant which affects the alpha 2-delta N-calcium channels. Its use in neuropathic pain has been established. Current FDA indications include post-herpetic neuralgia, diabetic polyneuropathy and fibromyalgia. In a study by Freynhagen, et al., evidence was presented regarding the analgesic effects of pregabalin in neuropathic pain of peripheral and central origin. Diagnoses included polyneuropathies, chronic radiculopathies, encephalitis disseminata, post-herpetic neuralgia, acute zoster infection, neuropathic cancer pain and complex regional pain syndromes. Pregabalin appeared to be beneficial in patients with neuropathic pain who are difficult to treat because of refractoriness to conventional pain medications, as well as improving sleep impairment and quality of life. A second study by Siddall, et al. suggested that pregabalin may be helpful in managing pain related to spinal cord injury. This double-blind placebo control study showed a statistically significant drop in pain scores at 12 weeks. Efficacy was sometimes seen as early as one week. In fact, this patient has reported good results with a trial of Lyrica. Therefore, the use of Lyrica (pregabalin) in the management of this patients neuropathic pain is supported by the evidence and is medically appropriate and indicated.