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

The enrollee is requesting reimbursement for residential treatment center level of care. The enrollee has alcohol use disorder, type 2 diabetes mellitus, hypertension, sleep apnea and acute encephalopathy. The patient indicated he started to drink alcohol in his twenties and had been drinking about three cups of hard liquor per day for years. The enrollee attended Alcoholics Anonymous meetings for about one year.  He is employed and worries that his drinking is affecting his ability to conduct business. He last drank two days before admission. He went through a detoxification process; after which he transferred to a residential treatment center level of care. Review of the records indicates the enrollee was not willing to move into sober living and he was unsure how long he would continue treatment. The records indicate it was imperative he utilize healthy coping skills, maintain relationships with his peers in the community, check in with his sponsor, and attend Alcoholics Anonymous meetings. The Level of Care Utilization System (LOCUS), is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. This tool was used in this review. The enrollees composite LOCUS score correlates with high intensity community based services. Medical evidence does not support the services at issue in this clinical setting.Final Result: The reviewer determined that the requested service was not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested two hours per week of in-home applied behavioral analysis (ABA) therapy for treatment of the enrollees behavioral health condition.  Three physician reviewers found that the submitted documentation fails to establish the medical necessity of the requested services. Based upon the documentation provided, the patient has been evaluated thoroughly by the school district and by a psychologist. Both evaluations note that the patient does not have any autistic traits. The evaluations conclude the patient has ADHD, borderline intellectual function and disruptive mood dysregulation disorder. Both evaluations provided extensive treatment recommendations. Furthermore, there is a lack of evidence in the literature to support use of ABA as a treatment modality for a patient who is not diagnosed with autism spectrum disorder.  Final Result:  Three 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: One reviewer is board certified in pediatrics with sub-specialty certification in developmental and behavioral pediatrics and is actively practicing.  Two reviewers are board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry 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 rituximab for treatment of his primary progressive multiple sclerosis. Findings:  The physician reviewer found that this patients presentation is consistent with primary progressive MS (PPMS). There is currently no U.S. Food and Drug Administration (FDA)-approved treatment for PPMS. Rituxan (rituximab) was studied in a multicenter placebo-controlled study and did not meet the primary endpoint of delaying disability. The authors concluded the drug was no more effective than placebo except in a small subset of men under age 50. Based upon the lack of compelling peer-reviewed data supporting the use of rituximab for the treatment of PPMS, there is inadequate evidence of the efficacy of rituximab to support its use in this setting. As such, the requested rituximab is not medically necessary for treatment of this patients medical condition. 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 in 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: Experimental/Investigational
Decision: Upheld

A 46-year-old female enrollee has requested Humira for treatment of her bilateral hearing loss due to autoimmune inner ear disability.  Findings:  Two physician reviewers found that this patient presents with autoimmune inner ear disease (AIED). Standard proven therapies as reported in the clinical trials and publications do not include the use of Humira in the treatment of AIED. To date, the studies suggest that Humira has limited use in humans and is generally not accepted as an established safe and effective treatment within this patient population. High-dose corticosteroids remain the only evidence-based treatment option in the treatment of AIED while steroid sparing immunosuppressive regimens have not been shown to be beneficial (Buniel and colleagues). Consistent with these findings, Ruckenstein and colleagues concluded that corticosteroids remain the mainstay of treatment and methotrexate has also not been validated as an efficacious therapy for patients with AIED. Moreover, Morovic Vergles and colleagues uncontrolled study in a small number of patients with AIED failed to demonstrate incremental benefits with Humira beyond that expected with standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injections for the left knee. This patient presents with complaints of severe left knee pain with associated swelling, popping, grinding and giving out. She has documented functional limitations with activities of daily living. Clinical examination findings are consistent with imaging evidence of severe left knee osteoarthritis in the medial compartment. She has failed to achieve adequate improvement in pain and function with conservative treatment, including corticosteroid injections, physical therapy, activity modification, and medications. Due to the patients age, the provider and patient are interested in delaying total knee replacement. The American Medical Society for Sports Medicine (AMSSM) supports hyaluronic acid injections in the knees for patients with severe osteoarthritis who have failed to respond to conservative treatment and to potentially delay total knee replacement in patients with pain that interferes with functional activity. Therefore, the requested Euflexxa injections for the left knee are medically necessary for 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 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

A 39-year-old female enrollee has requested for Fentanyl for treatment of her fibromyalgia and hip, knee and ankle pain. Findings:  The physician reviewer found that pure opioid agonists have long-term side effects on the immune and endocrine system, as well as the sleep system, the depression anxiety system and the gastrointestinal (GI) system that can be detrimental to fibromyalgia patients and other type of chronic pain patients if they are not monitored. The risk of patients obtaining narcotics outside of their prescribed dosage can exacerbate these risks and cause morbidities. Furthermore, the treatment of fibromyalgia is evolving with newer novel agents and opioid use in this illness is decreasing as better mechanisms of pain control are being elucidated; as such, a non-narcotic regimen may be the best course of action for this patient.  All told, there is no compelling evidence that this patient requires Fentanyl for pain control.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a four (4) wheeled power scooter for treatment of the enrollees obesity, leg edema, and difficulty with ambulation.  Findings:  The physician reviewer found that a recent physical therapy mobility evaluation indicated that the patient is able to transfer and ambulate short distances independently without a cane. He also has a cane which he uses. The evaluation noted good upper limb strength and functional upper limb range of motion. The patients home was noted to be inaccessible to entry or egress using a power mobility device. The available records do not indicate that the patient has neurological, musculoskeletal, cardiopulmonary or other organ system impairments that would preclude him from using a properly fitted manual wheelchair to accomplish the mobility-related activities of daily living that he would otherwise be unable to address with a cane or walker. Physical activity and the exercise afforded by these self-powered modalities of mobility, moreover, are recommended in the setting of obesity and for musculoskeletal health. All told, the requested a four (4) wheeled power scooter is not medically necessary for this patient.  Final Result: The reviewer determined that the requested equipment 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 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

The parent of a 5-year-old male enrollee has requested occupational therapy and speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the requested therapies. The patient was diagnosed with autism at the age of 3 years. Autistic children have delays in communication, which is an essential component of the diagnosis and difficulties in motor skills. Although speech therapy and occupational therapy are standard therapies for the treatment of autism, there is no evidence in this case that the patient has recently been evaluated by a speech therapist or an occupational therapist. The medical records provided included a psychological assessment, however no evaluations were provided for either of the requested therapies. Formal assessment by a speech therapist and an occupational therapist is required to confirm the patients deficits. Based upon the lack of clinical documentation provided, specifically the lack of both a speech and occupational therapy evaluation for the patient, the requested therapy is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 43-year-old female who presents with neck and back pain as well as right side upper extremity pain. No cause or incident for the pain is evident. Chiropractic care has been provided 18 times over several months. The patient indicates she is in constant pain and is unable to work despite a recent course of chiropractic care. The patient notes on the chiropractic intake forms that her complaints are all the time, extreme, and she has neck pain on swallowing. An x-ray exam has been requested by the chiropractor but the submitted documentation does not indicate if the exam was performed. The patient has requested authorization for continued chiropractic care. The Health Plan has denied the patients request on the basis that continued chiropractic care is not medically necessary for treatment of the patients medical condition.Upon review of the patients records it appears she has made little progress with chiropractic care. Additionally, the submitted records do not demonstrate that other causes for the patients arm complaints have been ruled out or that referrals have been made. Chiropractic care has been given an adequate opportunity to cure or relieve the patients pain. Continued chiropractic care is not likely to be clinically beneficial to this patients current complaints. The patient should receive a referral to her primary care physician for further workup or a referral to rule out other causation or to suggest possible curative care approaches. Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 57-year-old female has requested radiofrequency neurolysis for treatment of her pain.  Findings:  Two physician reviewers found that the submitted documentation indicates that prior radiofrequency ablation resulted in one year of significant relief.  Per the medical records, the Health Plan has indicated that results of a short-term nerve block are needed prior to approving the requested services.  Specifically, the Health Plan noted that the short-term nerve block needs to reduce the patients pain by at least half.  This patient has chronic low back pain with no radiation into the lower extremities and without any neurological dysfunction.  Prior radiofrequency ablation provided one year of significant relief.  The current medical evidence supports the requested services in this patients case.  Radiofrequency neurotomy has been demonstrated to be an effective modality in managing chronic lumbar facet joint pain.  The average relief with a single radiofrequency neurotomy is approximately six months.  In this patients case, there is no history of any additional injury, and it has been have shown that radiofrequency can be effective even in patients without diagnostic blocks.  Further, it is not necessary to perform diagnostic blocks prior to each radiofrequency neurotomy as pain recurs.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for two hours of individual speech therapy per week and two hours of social skills group therapy per week. Researcher has found that available evidence shows that highly structured behavioral methods have important positive consequences for children with autism. Colleagues have concluded that behavioral-based interventions are evidence-based to teach speech to non-verbal individuals or individuals with low levels of vocalizations at baseline. In this case, the submitted documentation reflects that the patient continues to have significant language deficits and difficulties and that an increase in speech therapy to two hours of individual speech therapy per week may be expected to improve his speech capabilities as well as have additional positive behavioral consequences. In addition, the patient is noted to have severe deficits in social interaction, and the highly structured behavioral methods provided by two hours of social skills group therapy per week may reasonably be expected to lead to improvement in the patients condition. Accordingly, two hours of individual speech therapy per week and two hours of social skills group therapy per week are medically necessary for treatment of the patients medical condition at this time.Final Result: The reviewer has 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 both 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 27-year-old female enrollee has requested acute psychiatric hospitalization services for the treatment of her bipolar disorder. Findings:  The physician reviewer found that the Interdisciplinary Progress Notes report that the patient felt good and had no thoughts or feelings of hurting herself.  The patient was reported as being in very good spirits and was ready to go home.  These notes also state the patient was eating well and smoking and getting along well with peers and staff.  The patient was no longer suicidal or a danger others.  There were no acute psychotic symptoms.  There was no grave disability, and there was no self-injury or uncontrolled risk-taking behaviors.  The patient had reached the maximum benefit from acute inpatient care.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a seven-year-old female enrollee has requested authorization and coverage for growth hormone therapy with Genotropin (somatropin) for treatment of the enrollee's idiopathic short stature.Findings:  The physician reviewer found that the request for growth hormone therapy with Genotropin (somatropin) is medically necessary for treatment of the patients medical condition. According to the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 SDs below the mean for age or more than 2 SDs below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than 2 SDs below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. In this case, the patient meets most of the above criteria. The patients height is more than 3 SDs delayed, her growth velocity is poor, and her bone age is markedly delayed. In addition, with normal growth factors, GH stimulation testing is not indicated, as the patient is not likely to have classic GH deficiency. The patient meets standard U.S. Food and Drug Administration (FDA) criteria for a trial of GH for treatment of idiopathic short stature.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 with sub-specialty 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

A 78-year-old male enrollee has requested skilled nursing facility (SNF) services for the treatment of his multiple injuries. Findings:  The physician reviewer found that the patients condition does not respond to therapeutic pharmaceuticals. Brain healing determines progress. The submitted documentation reveals that continued PT showed a decline from the peak. The patient was progressing with OT, but the rate and area of progression indicate limited capacity to regain function. As discussed in the paper by Gordon et al., the progress for recovery following traumatic brain injury can continue for extended periods of time, but the extent of brain injury and the rate of brain injury determine the rate of functional recovery. Continued PT and OT cannot hasten functional recovery in the absence of brain recovery, nor do they promote brain recovery. Because the patient was progressing and did progress, the Health Plans denial should be overturned for the first round of therapy and upheld for the second round.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 57-year-old female with a history of brain surgery for a tumor. The patient has cognitive defects, fatigue and depression. She has been treated with multiple medications. A combination of Aricept and Provigil has improved the patients cognitive functioning and mood. At issue is whether Provigil is medically necessary for treatment of the patients condition.The patient has benefited from her current combination of medications. Trials of other stimulants and antidepressants were not as beneficial. Provigil is significantly safer than amphetamines or Ritalin for this patient. It is used in the psychiatric community off-label for the treatment of depression, fatigue, and poor concentration with good results. As such, continuation of Provigil is medically appropriate and indicated in this clinical setting. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco. The submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has chronic non-malignant pain which was previously treated with opiate analgesia. Clinical practice guidelines do not support restarting opiates for nonmalignant pain, such as chronic low back pain. The long-term outcomes for chronic low back pain are worse with opioids than other therapeutic approaches. Therefore, Norco 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 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: Medical Necessity
Decision: Upheld

A representative of a 50-year-old female enrollee has requested for a motorized scooter for her mobility. Findings:  The physician reviewer found that there is no documentation that the patient would be unable to propel a manual wheelchair. As other assistive options exist, a motorized scooter is not required.