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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for fentanyl (Actiq) 600 mcg LPOP, quantity 90; fentanyl (Actiq) 400 mcg LPOP, quantity 90; fentanyl (Actiq) 400 mcg LPOP, quantity 60; fentanyl (Actiq) 200 mcg LPOP, quantity 60; and fentanyl (Actiq) 200 mcg LPOP, quantity 30. The Centers for Disease Control and Prevention (CDC) guidelines on opioid prescribing suggest comprehensive steps at all stages of opioid initiation, monitoring, continuation, and discontinuation. The CDC guidelines note clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patientBefore starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. The guidelines also note 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.This review focuses on a period of tapering treatment of opioid, rather than opioid maintenance. During the timeframe under review, opioid weaning took place for this patient who had been on long-acting morphine with fentanyl breakthrough for several years. Therefore, a weaning process off fentanyl would typically involve a slower course. The only alternative would have been for the patient to have undergone a detoxification process. Based on the records, a reduction of this high of dosage of Actiq on an outpatient basis as performed in this case was medically appropriate. Therefore, fentanyl (Actiq) 600 mcg LPOP, quantity 90; fentanyl (Actiq) 400 mcg LPOP, quantity 90; fentanyl (Actiq) 400 mcg LPOP, quantity 60; fentanyl (Actiq) 200 mcg LPOP, quantity 60; and fentanyl (Actiq) 200 mcg LPOP, quantity 30 were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 46-year-old female enrollee has requested artificial disc replacement at C3-C4 and fusion at C4-C5 for treatment of her degenerative disc disease.  Findings:  Three physician reviewers found that artificial disc replacement at C3-C4 and fusion at C4-C5 is not likely to be more beneficial for treatment of the patients medical condition than any available standard treatment. According to the study by Nandyala and colleagues, their evaluation revealed that there were no significant differences in the risk for postoperative complications between the two surgeries and concluded that further studies are warranted to characterize the long-term complications and patient outcomes between cervical disc replacement versus anterior cervical discectomy and fusion (ACDF). The peer-reviewed literature cited above indicates that further studies are needed to demonstrate the overall efficacy and safety of this hybrid procedure versus a two-level fusion. A total disc replacement at this time is only considered potentially reasonable for single level degenerative disc disease. The MRI reveals that this patient has multi-level degenerative disease of the cervical spine. Therefore, this requested procedure is not likely to be more beneficial than the standard of care.
Appeal type: Experimental/Investigational
Decision: Overturned

A 48-year-old female enrollee has requested for hyperbaric oxygen (HBO) therapy for treatment of her postoperative suture line. Findings:  Two physician reviewers found that HBO potentially minimized the amount of eventual debridement and allowed primary closure of the defect.  HBO has been shown to be of benefit in clinical situations such as described in this case.  The main problem is that there is no other available standard form of therapy that could potentially alter the inevitable progression of tissue ischemia to tissue necrosis that in this case might have required more extensive reconstruction, including skin grafting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for music therapy services. The submitted documentation fails to demonstrate the medical necessity of the requested services. A recent review of music therapy in mood disorders in children and adolescents concluded that music-based interventions may be efficient in reducing the severity of internalizing symptoms in children and adolescents. While these results are encouraging with respect to the application of music-based intervention, rigorous research is necessary to replicate existing findings and provide a broader base of evidence. More research adopting well controlled study designs of high methodological quality is needed. Studies show that more research on the efficacy of music therapy in children and adolescents with psychiatric illness is needed. Studies show  that no significant effects were found for two trials involving children with mood disorders and related psychopathology. These findings offer limited qualitative evidence to support the effectiveness of music on health-related outcomes for children and adolescents with clinical diagnoses. The current medical evidence does not support the requested services in this clinical setting. Therefore, music therapy services are 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for panniculectomy. This patient presents with evidence of a relatively mild overlapping lower abdominal pannus in the setting of a ventral hernia. Based on the submitted documentation, there is insufficient medical documentation to support that the panniculectomy is required to address a functional deficit. From the American Society of Plastic Surgeons (ASPS) a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. Further, researchers noted that, abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus. Panniculectomy can treat these symptoms. Given the documentation provided for review, this patient has not been shown to have functional impairment directly related to her relatively mild lower abdominal pannus. No other justification has been provided to support the panniculectomy, as it is related to the ventral hernia. Thus, the requested panniculectomy is not medically necessary for this patient.In addition, the patients abdominal pannus does not constitute an abnormal structure of the body based on the patients size. The requested surgery is not being performed to repair a functional impairment. Moreover, the surgery will not provide a more than minimal improvement in the patients appearance. All told, the requested panniculectomy is not supported as reconstructive in nature or medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary and are not reconstructive in nature 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 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: Urgent Care
Decision: Overturned

A 33-year-old female enrollee has requested emergency services for the treatment of her condition. Findings:  The physician reviewer found that the patient was suffering from significant pain and that she was concerned that she might have a contagious infectious disease such as strep throat.  Due to her discomfort and fear of jeopardy to her health and the health of her infant, it is reasonable that a prudent layperson would seek immediate medical attention in that situation.  The differential diagnosis of the patients presenting symptoms include strep throat, pneumonia, bronchitis, sinusitis, otitis media, and other potentially serious infections which could have required specific therapy such as antibiotics and respiratory medications.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 12-year-old male enrollee has requested inpatient psychiatric treatment for treatment of the enrollees anxiety disorder, not otherwise specified, oppositional defiant disorder, and intermittent explosive disorder.   Findings:  The physician reviewer found that this patient was hospitalized on due to aggressive behavior. The mental status examination indicated no psychosis and no suicidal or homicidal ideation.  The patient did not want to speak, but he was cooperative during physical examination.  He participated in groups.  During his hospital stay, he was maintained on a mood stabilizer.  The patient was discharged with diagnoses of intermittent explosive disorder, anxiety disorder, not otherwise specified, and oppositional defiant disorder.  Based upon the submitted documentation, the medical necessity for treatment in an inpatient setting has not been established.  Community standards of care, including the American Academy of Child and Adolescent Psychiatry treatment guidelines, support treatment in a less restrictive setting. The patient could have been safely and effectively treated at an intensive outpatient level of care. All told, inpatient psychiatric treatment provided on the dates in question was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for substance use residential treatment center servicesfor treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity for the services at issue in this clinical setting. The patients comorbid anxiety and depression were well controlled on medication. The patient did not have a psychiatric condition or medical illness that required treatment at the residential level of care. The patient was motivated in his quest for sobriety. The patient was employed and had safe housing.  At the time of discharge from detoxification treatment, the patient was improved and motivated for recovery. It was recommended that he have a follow up visit with the patients community provider in six weeks. During the episode of illness, the patient had no history of chemical dependency treatment such as community programming, outpatient counseling, anticraving medication, intensive outpatient services, partial hospitalization or placement in a sober living environment. The medical literature recommends treatment in the community as outcome measures and therapeutic gains are optimized in this environment. Additionally, the patient previously achieved sobriety after a week long admission followed by Alcoholics Anonymous. There was no evidence to suggest that similarly comprehensive, evidence based services provided in a less restrictive treatment setting would have been insufficient or inadequate at the time in this patients case.  Although addiction specialty services were indicated, the clinical documentation does not demonstrate the medical necessity of treatment in a 24 hour supervised setting during the disputed timeframe.  Therefore, the substance use residential treatment center services were not medically necessary for the treatment of this patients medical condition.  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 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: Upheld

A 45-year-old female enrollee has requested inpatient substance abuse rehabilitation services for the treatment of her opiate and alcohol dependence. Findings:  The physician reviewer found that the patient could have been safely and effectively treated at a lesser level of care during the dates of service at issue. A methodology for the selection of the appropriate rehabilitation setting for patients with dual diagnoses (substance abuse and psychiatric comorbidities) is outlined in the American Society of Addiction Medicine (ASAM) criteria. This patient went through the detoxification process as an inpatient and was medically stable from that standpoint, having been started on Subutex. Although she had a diagnosis of depression, she was not suicidal and had been started on treatment. She was compliant with treatments. As such, she did not have any indication for continued acute hospitalization. While she still required treatment of her condition, there were no documented circumstances that would indicate that this could not be safely and effectively undertaken at a lower level of care.
Appeal type: Medical Necessity
Decision: Upheld

A 92-year-old female enrollee requested a Hoyer sling.Findings:  The physician reviewer found that mechanical transfer devices are well-accepted instruments in the care of patients who are dependent for mobility, both for patients and caregiver safety (Edlich, et al; Collins, et al). This patient is chronically dependent for transfers and has been transferred, appropriately, using a Hoyer lift patient transfer system. However, the medical records do not establish the need for an additional Hoyer sling that is being requested in this case. The records from the patients treating providers do establish that the patient is dependent for transfers, but do not establish that the patients current slings are in disrepair or in need of replacement. Based on the available documentation, the requested additional sling for the patients Hoyer lift is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

enrollee has requested authorization and coverage for a referral to see a pulmonologist. The Pulmonary Hypertension Association (PHA) recommends including a pulmonologist in the treatment of patients with pulmonary hypertension. Here, the patient is noted to have multiple pulmonary issues including pulmonary hypertension, tuberculosis and an abnormal chest xray. Given this patients medical history and per PHA guidance, a referral to a pulmonologist is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage of Sovaldi with ribavirin for a duration of 24 weeks. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America (AASLD/IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions regardless of fibrosis stage. Per the guidelines, patients with cirrhosis are high priority for treatment.  The guidelines do not recommend Harvoni as a treatment for genotype 3, hepatitis C as its ledipasvir component does not have sufficient activity against this genotype. Therefore, the patient has never received an effective treatment for hepatitis C, and should be considered treatment naive.  For treatment naive, genotype 3 patients, the guidelines recommend two effective regimens, but no longer recommend Sovaldi with ribavirin as primary or re-treatment therapy for genotype 3 hepatitis C due to lower efficacy. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication regimen is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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 37-year-old male enrollee has requested wrist surgery (3D osteotomy correction) for treatment of his malunion.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested procedure. Wrist surgery with 3D osteotomy correction is medically necessary in order to correct the patients malunion. 3D osteotomy correction should include computed tomography (CT) scanning to allow for planning of the osteotomy and the need for bone graft, including type and shape of the graft, and will allow planning as to interval fixation. CT scanning with 3D imaging will also assess articular disruption incongruity and step offs of the joint surfaces which may not be correctable while angulation and radial shortening may be correctable. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested procedure is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Qbrexza. Hyperhidrosis can consist of severe sweating in the axilla, palms of the hands, and soles of the feet. McConaghy and Fosselman noted that the typical progression of treatment includes topical therapies with over-the-counter antiperspirants, Drysol, iontophoresis, oral anticholinergics, and Botox injections. The records provided for review document that this patient has a history of eczema. The patients provider noted that the patients history of eczema precludes him from using Drysol. The medical literature supports treatment with short contact time application of Drysol, application of petroleum jelly, and over-the-counter antiperspirants or oral anticholinergics. The patients history of eczema should not preclude treatment with Drysol since eczema should not be considered a contraindication. All told, the requested Qbrexza 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 dermatology 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a genetic test for peripheral neuropathies for evaluation of his medical condition.  Findings:  Two physician reviewers found that there is a lack of support for the services at issue in this patients case.  The patient has had a chronic polyneuropathy that in the past reportedly responded to intravenous immune globulin, thus was presumed to be immune-mediated. Genetic neuropathy such as Charcot-Marie-Tooth disease is not likely to respond to intravenous immune globulin.  Guidelines for evaluation of symmetric polyneuropathy suggest that patients without a known cause should undergo a complete blood count, comprehensive metabolic panel, Vitamin B12, thyroid testing, serum protein electrophoresis with immunofixation, fasting glucose measurement, and glucose tolerance test.  There is no evidence in this case that other relevant metabolic, infectious, autoimmune, and toxic etiologies have been excluded.  Genetic testing is established as useful for diagnosis and classification of hereditary neuropathies.  However, it is not likely to lead to treatment options.  In sum, genetic testing for peripheral neuropathies was not likely to have been more efficacious than other modalities.  Final Result: Two reviewers determined that the services at issue were not likely to be more beneficial for evaluation 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 neurology 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.