Persius/imr-appeals huggingface dataset:
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. In this case, objective treatment goals for pain and function were not documented. Clinicians should use caution when prescribing opioids at any dosage. Dose escalation is not a long-term plan, but a short-term plan for the treatment of tolerance. It is reasonable to consider alternatives to opioids and to wean the patient off opioids. In this patients case, not all non-opioid medications classes have been optimized or tried. For these reasons, 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: Urgent Care
Decision: Overturned

A 46-year-old male enrollee has requested emergency services for the treatment of his abdominal pain. Findings:  The physician reviewer found that the patient complained of generalized abdominal pain since 12 noon, rated as 8/10, and associated with nausea, diarrhea and myalgias. The patients symptoms met prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and the sudden onset of severe abdominal symptoms would reasonably expect the absence of emergency care to jeopardize their health. Although the medical record does not support the patients claim that he was having chest pain and arm numbness, the severity of his abdominal complaint is evident.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a two-year-old male enrollee has requested  coverage for Applied Behavioral Analysis (ABA) therapy treatment at the frequency of six hours per week for treatment of his reported autism spectrum disorder.  Findings:  The physician reviewer found that based on review of the available records, this patient has many behaviors suggestive of Autism Spectrum Disorder (ASD) but a formal evaluation is needed to provide a diagnosis. As noted in the medical literature by Volkmar and colleagues, this confirmation of diagnosis is important to insure that other possible conditions are not the cause of the patients behaviors as they may require varied treatments. Certain behavioral features are required for a diagnosis of autism, although they are sometimes observed in other disorders by themselves. Once a diagnosis has been established, there is substantial support for the medical necessity of ABA therapy for children with ASD (Johnson, et al). The American Academy of Pediatrics (AAP) guidelines note that if a positive screen for ASD is noted, then the patient is referred for a comprehensive ASD evaluation and audiological evaluation. If indicated, early intervention/early childhood education services are then provided targeting the patients unique deficits with modifications in intervention strategies as needed. In this case, it is unclear what medical condition the proposed ABA therapy is targeting. In addition, the patient may require more than six hours per week of ABA therapy if ASD is in fact diagnosed. For these reasons, it is appropriate at this time to have the patient undergo a thorough work-up to determine the etiology of his delays as recommended by the Health Plan. In addition, the Health Plans approval of Autism Services Therapy (AST) under CPT code H0031 for up to 15 hours of ABA assessment services appears reasonable. Therefore, the requested ABA therapy for six hours per week has not been established as medically necessary for treatment of this patients medical condition at this time pending the outcome of a more thorough diagnostic evaluation.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has reimbursement and prospective authorization and coverage for ultrasound/phonophoresis twice per week. Findings:  The physician reviewer found that meta-analysis of randomized clinical trials of different treatments for androgynous temporomandibular disorder, Al-Moraissi and colleagues concluded that the most effective treatments for short-term and intermediate-term improvement were arthroscopy procedures, followed by platelet-rich plasma (PRP) and hyaluronic acid injections, and non-invasive therapies including physical therapy. The authors did not mention phonophoresis as a recognized treatment option with strong medical evidence. In reviewing the efficacy of phonophoresis in patients with temporomandibular disorders, Ramakrishnan and Aswath noted that while both phonophoresis and ultrasound therapy were effective in treating temporomandibular joint disorders, improvement with phonophoresis over traditional ultrasound did not demonstrate statistically significant evidence of superiority. In this case, the patient reports a two year history of chronic facial pain and temporomandibular joint pain. While she reports improvement with ultrasound treatments along with phonophoresis, current medical literature does not support the use of phonophoresis as standard of care for temporomandibular joint disorders. Therefore, ultrasound/phonophoresis twice per week were not and are not likely be more beneficial than any other available standard service for the patients medical condition.Findings:  Two of the three physician reviewers found the requested ultrasound/phonophoresis twice per week were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine 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 authorization and coverage for acupuncture. The use of acupuncture to treat impingement syndrome has been demonstrated to be a safe and reliable technique with associated good results. When compared to sham acupuncture, trigger point acupuncture revealed decreased pain intensity with improved shoulder function. The authors found a significant decrease in pain noted at five weeks in the trigger point treated group. This patient presents with chronic left shoulder pain associated with a superior labral tear and evidence of impingement and scapulothoracic pain. Given his symptoms, the patient should benefit from the requested acupuncture treatment as noted in the current medical literature. Therefore, the requested acupuncture is medically necessary for treatment of this patients left shoulder pain. 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Mohs surgery. For patients with superficial basal cell cancer (BCC) of the scalp, Mohs surgery may be appropriate if the lesion is greater than or equal to 6 mm. In this case, the patient has superficial basal cell carcinoma located on his scalp which measures  8 x 8 mm. Given the patients young age, and that he has successfully been treated with the Mohs technique before, Mohs surgery is appropriate in this case. Therefore, the requested Mohs surgery is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Gelsyn-3 injections in both knees. An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patients options were limited. The patient had tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties. As such, Gelsyn-3 injections in both knees were medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the service 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 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 22-year-old male enrollee has requested residential center treatment services for treatment of his substance use disorder. Findings:  The physician reviewer found that an analysis of the patients records reveals that the patient was a candidate for treatment in a less restrictive level of care, such as partial hospitalization, or other intensive outpatient services. This finding is consistent with the level of care utilization system (LOCUS) for psychiatric and addiction services and the American Psychiatric Association (APA) treatment guidelines, which recommend intense community-based level of care whenever possible. This patients records report no co-morbid conditions or acute symptoms that necessitated intense 24-hour supervision.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia services. The documentation provided for review indicates that this patient had an ASA preoperative physical status classification score of 1. In this clinical setting, intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well supported in the current peer-reviewed medical literature, given a low preoperative physical status classification score. All told, the requested reimbursement for anesthesia services was not medically necessary for evaluation of the 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 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

The parent of a thirteen-year-old female enrollee has requested residential treatment services for the treatment of the enrollees condition. Findings:  The physician reviewer found that the patient clearly needed a variety of therapies, but her particular need for residential care was not justified or specified. The services she needed could have been provided at a lesser level of care such as partial hospitalization program or intensive outpatient program. There was limited psychiatrist contact, and many of her therapies are of questionable utility (neurofeedback, biofeedback, EMDR and nutritional supplementation). I am also seriously concerned with the concept of keeping a child in residential care for more than two years, especially when the care was not in very close proximity to her home. The value of telephone therapy in situations like this is limited. Residential services were not medically indicated for the entire period in question.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old male enrollee has requested a C-Leg ABLE II prosthetic microprocessor controlled knee for treatment of his above the knee amputation.  Findings:  The physician reviewer found that a microprocessor controlled knee is considered safe and energy efficient for appropriate candidates. Per the Centers for Medicare and Medicaid (CMS) guidelines, a patient with a K3 or above function is considered such a candidate. From a review of the available records, it appears that this patient was not yet walking at the time the microprocessor controlled knee was requested. Thus, despite being very active previously, there is insufficient documentation that the patient will achieve a functional level of K3 or above given the extensive right leg trauma. In order to be considered for the requested prosthetic equipment, the patient must demonstrate K3 or above ambulation. Therefore, the requested microprocessor controlled knee has not been demonstrated to be medically necessary at this time.
Appeal type: Experimental/Investigational
Decision: Upheld

A 42-year-old female enrollee requested authorization and coverage of gastric banding for the treatment of morbid besity.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that gastric banding is not likely to be more beneficial for treatment of the enrollees morbid obesity than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested a residential treatment center that offers a long-term residential treatment program of up to 12-18 months in length for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the request for a residential treatment center that offers a long-term residential treatment program is medically necessary for this patient. The patient has a history of unstable, unpredictable and violent verbal and physically abusive behavior. She is unable to tolerate any degree of frustration, stress, or questioning of her behavior/conduct without aggressive behavior. She requires a highly structured setting to provide treatment and contain her explosive and unpredictable behavior, which is not only imminently dangerous to herself, but to her family and potentially the public. The patient needs to learn coping skills and distress tolerance, in an environment which provides a high level of containment and within which she will be able to practice these skills safely, for herself and others. Should the pattern of early termination of services continue, it is likely the patient may become a serious threat to the public.  Thus, 24-hour structured monitoring in a residential setting, for at least six months and in a residential treatment center that offers a long-term residential treatment program is medically necessary. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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

An enrollee has requested reimbursement for residential treatment center level of services. The submitted documentation supports that residential treatment center level of services at issue were medically necessary. Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient met Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. The submitted documentation thereby reflects that the patient required a safe and stable living environment in order to develop his recovery skills, thus qualifying for ASAM Level 3.5 treatment at least, which is similar to what the patient received at the facility. Treatment may be required at Level 3.5 if an individual is not progressing and faces imminent danger if not in a supportive treatment setting. Given the severity of the patients illness, residential treatment center level of services were clinically appropriate for the patient's illness. Therefore, the residential treatment center level of services at issue were medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat 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

The parent of a 15-year-old female enrollee has requested partial hospitalization program (PHP) level of care services for treatment of the enrollees eating disorder and major depression.  Findings:  The physician reviewer found that the records provided for review support the medical necessity of the PHP level of care for treatment of this patients medical condition. The patient does have strong suicidal thoughts and even has a plan, and her parents have been taking precautions. The patients symptoms include bradycardia and dizziness, yet the patient does not have an understanding of her anorexia, and would like to leave the program and continue her weight loss regimen. For these reasons, the patient meets the guidelines from the American Psychiatric Association (APA) for the requested PHP level of care services.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for Otezla 30 mg tablets. Otezla (apremilast) is an FDA-approved, systemic, oral, non-biologic medication used to treat chronic psoriasis with good safety and efficacy profiles. Papp and colleagues performed a phase 2b, multicenter, randomised, placebo-controlled, dose-ranging study and concluded that apremilast, given orally at 20 or 30 mg twice daily, seems to be efficacious, safe, and tolerable for patients with moderate to severe plaque psoriasis. In addition, joint American Academy of Dermatology-National Psoriasis Foundation guidelines give an A rating to the use of apremilast for psoriasis in adults. Specifically, the guidelines state that apremilast is recommended for the treatment of moderate to severe psoriasis in adults. In this case, the patient has chronic plaque psoriasis that requires systemic treatment. Records reflect that the patient is currently responding to Otezla, and the medication is standard of care in the treatment of chronic plaque psoriasis. Under these circumstances, the requested Otezla 30 mg tablets are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.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 topographic genotyping (PathFinder TG Test) for evaluation of his pancreatic lesion. Two physician reviewers found that the testing at issue was not likely to be more effective for this patient than other available treatment options. This test was ordered in the context of a patient with a small pancreatic cyst. In this clinical setting, the standard of care is close surveillance with observation with an increase in size triggering a more invasive intervention. Recent guidelines indicate that molecular markers remain an emerging area of research, and the diagnostic utility of these tests is uncertain. For the reasons provided, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Final Result:  Two reviewers determined that the testing at issue was 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: One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One reviewer is board certified in medical oncology and is actively practicing.  One reviewer is board certified in medical oncology and is 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.