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

Nature of Statutory Criteria/ Case Summary: The enrollee has requested reimbursement for residential treatment center services. The enrollee has a history of bulimia nervosa, body dysmorphia, depression, and anxiety. She denied suicidal/homicidal ideations or psychotic symptoms. She remained in RTC when she stepped down to a partial hospitalization program.  Findings:  The physician reviewer found that the necessity for residential treatment is based upon an evaluation of specific criteria. These criteria include: medical status, suicidality, weight as percentage of health body weight, motivation, co-occurring disorders, structure needed for eating/gaining weight, ability to control compulsive exercising, purging behavior and environmental stress. The enrollees laboratory values and vital signs were normal. Her admission weight was over ideal body weight. She would qualify for this level of care if her weight were <85% of ideal body weight. She had no suicidal ideations or co-occurring mental disorder. Final Result: The reviewer determined that the requested therapy 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: Overturned

A 28-year-old female enrollee requested partial hospitalization program (PHP) services for medical treatment of her bipolar disorder. Findings:  The physician reviewer found that based on the available records, the PHP services provided to this patient were medically necessary for treatment of this patients medical condition.  Discharge from the acute psychiatric inpatient unit to the PHP level of care in this case represented a safe and appropriate disposition consistent with good medical practice. In addition, the availability of the PHP likely shortened the patients length of stay in the more restrictive inpatient setting. The PHP services provided to this patient were for active treatment and diagnostic purposes and were reasonably expected to improve the patients condition and expedite a seamless transition to the outpatient and community-based treatment setting. For these reasons, the PHP services were medically necessary for treatment of this patients bipolar disorder.
Appeal type: Medical Necessity
Decision: Upheld

A forty-one year-old female with marked obesity, degenerative joint disease, stress-related symptoms, disturbed sleep, chronic headaches, fibromyalgia, and recurrent sinusitis is requesting reimbursement and prospective authorization of Ambien CR.  The patient had been treated with one other sleep aid with limited benefit and is said to be sleeping better with Ambien CR.Reviewers Findings:The reviewing physician found that it is not unreasonable for the Health Plan to require a trial of two formulary agents with a demonstrated lack of efficacy, before authorizing Ambien CR.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for two Durolane injections (HCPCS J7318) in the right knee.Current medical literature pertaining to viscosupplemention 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 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. As such, the academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. 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, arthroscopic surgery and a cortisone injection were not beneficial, and the only alternative was a total knee arthroplasty. Accordingly, the two Durolane injections (HCPCS J7318) in the right knee 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 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 53-year-old female enrollee has requested Hyalgan injections to the right knee for the treatment of her condition. Findings:  The physician reviewer found that the requested Hyalgan injections for degenerative joint disease of the right knee do not appear to be medically necessary at this time.  There was a right knee examination documenting some tenderness and patellofemoral crepitus with x-ray describing patellofemoral degenerative changes.  While Hyalgan is used for the treatment of osteoarthritis in patients who have failed to respond adequately to conservative care (including anti-inflammatory medication and home therapy exercises), there is no documentation in the medical record that any conservative care was done for the right knee. In light of the lack of documentation of failure of conservative care, there is no specific medical indication for the requested series of Hyalgan injections for this patients right knee.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old female enrollee has requested septoplasty with bilateral inferior turbinate resection including facility services and general anesthesia for treatment of her left-sided septal deviation with inferior turbinate hypertrophy.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  There is no documentation of nasal airway obstruction or any functional impairment before surgery to justify the medical necessity of nasal surgery.  Nasal airway obstruction can be due to septal deviation, enlarged turbinates, engorged or hypertrophic nasal mucosa, masses within the nose, or external or internal nasal valve collapse.  In this patients case, the reviewed materials do not document the presence of these conditions prior to surgery.  Additionally, the preoperative photographs do not show any condition that would constitute an abnormal structure of the body.  Thus, the services at issue were not reconstructive in nature.  All told, septoplasty with bilateral inferior turbinate resection including facility services and general anesthesia provided on the said date were not reconstructive in nature and were not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old male enrollee has requested laser therapy for treatment of his peripheral neuropathy. Findings:  Three physician reviewers found that in this patients case, the requested laser therapy is not likely to be superior over other available treatment modalities.  There is a lack of scientific support for the use of low level laser therapy to treat neuropathy.  There are several studies which indicate there are no significant differences in visual analog scale (VAS) pain scales in treated versus untreated patients.  At this time, there is a lack of evidence to suggest laser therapy has any role in the treatment of neuropathy.  Thus, the requested services are not likely to be more efficacious than other options for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for Optune E0766-electrical stimulator device for treatment of her brain cancer (glioblastoma). Findings:  Three physician reviewers found that anaplastic astrocytoma and glioblastoma multiforme are high grade tumors that are best treated with resection, radiation therapy, and chemotherapy. The standard of care is to resect the GBM maximally followed by treatment with temozolomide.  Most GBM tumors recur and then the treatment options are limited.  This patient has exhausted all these options. In 2011, the U.S. Food and Drug Administration (FDA) approved Optune, formerly known as the NovoTTF-100A device, to deliver alternating electrical fields to treat recurrent GBM. The approval was based on a randomized clinical study where 237 patients got either Optune versus best standard of care chemotherapy (including bevacizumab). This study noted that there was no difference in overall survival between the two modalities. Moreover, the National Comprehensive Cancer Network (NCCN) have now included Optune device in their treatment flow charts. Follow up analyses have backed up the results on its efficacy. Recently, the FDA expanded the indication for Optune to include newly diagnosed GBM when used along with temozolomide and radiation therapy. This decision was based on a randomized clinical trial where 695 patients were analyzed for Optune in combination with temozolomide compared with temozolomide alone. The Optune device, in combination with the standard treatment, resulted in prolonged overall survival.  Final Result: The reviewers determined that the device at issue was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and is 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: Upheld

A 44-year-old female enrollee has requested blue light photodynamic therapy for the treatment of her rosacea. Findings:  The physician reviewer found that the patient is requesting coverage for blue light photodynamic therapy for treatment of her permanent telangectasias associated with chronic rosacea. This patients medical management of rosacea has not been optimized.  There is no indication from the medical records that the patient has been treated with low dose oral antibiotics including doxycycline, which is a standard approach to reduce inflammation in patients with this condition according to Modi and colleagues. In addition, Korting and Schollmann suggest topical treatments including sodium sulfacetamide-containing washes or creams, and topical azaleic acid creams that can reduce inflammation. There is no objective documentation of recent trial and failure of these therapies in the records provided for review. The use of blue light photodynamic therapy is not supported in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 49-year-old male enrollee has requested balloon sinus ostial dilation under anesthesia for treatment of his chronic maxillary sinusitis.  Findings:  Two physician reviewers found that review of the scientific literature demonstrates that balloon sinus ostial dilation (balloon sinuplasty) is a proven procedure. It is widely utilized in patients who meet clinical indications for sinus surgery. In the case of this patient, there is inadequate evidence that the patient meets clinical indications for surgery. Specifically, the submitted documentation indicates that the patient experiences 1-2 episodes of acute sinusitis per year. Based upon the patients degree of symptomatology, he does not meet clinical indications for balloon sinuplasty. Therefore, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee has requested 61 external urethral clamps per year for treatment of his urinary incontinence.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested equipment. The manufacturer of C3, male continence device, suggests that the device be discarded after approximately one week of use. The manufacturer instructions further point that it should not be cleaned or washed as this will compromise its effectiveness. In my professional experience, clamps generally last longer than a week. In this patients case, the Health Plans approval of 52 clamps per year (4 clamps a month) is reasonable and medically necessary. Therefore, the requested 61 external urethral clamps per year are not medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and continuous coverage of a skilled nursing facility, level II care from 8/22/18 forward. Per a study, mild to moderate nonpurulent skin/soft tissue infections such as limb cellulitis are treated with intravenous and/or oral antibiotics. Another study note that lymphedema is a chronic condition that is managed with interventions such as manual decompression, limb compression pumps, compression wrapping/taping, compression sleeves and skin care The records in this case indicate that the patient was on oral antibiotics upon admission to the skilled nursing facility on 7/19/2018, with an order for a course of one week. Nursing evaluation did not note any significant wounds, skin lesions or other need for skilled nursing care with respect to his admission diagnosis of cellulitis. The patient was receiving topical creams on his legs twice a day. There were and still are no indications that the patient required skilled nursing facility level care on 8/22/2018 forward for treatment of cellulitis, leg swelling or lymphedema. From the therapy/functional standpoint, the patient underwent a prolonged therapy program and slowly made some gains in his functional status. As of mid-August 2018, he was requiring stand by assist for transfers and he was ambulating 75 feet with a cane at contact guard assist. He was contact guard assist for lower body dressing and toileting. This level of function constituted only a minimal level of improvement over the course of several weeks. He had dysphagia but made no progress from his initial swallowing status of pureed consistency for solids. There are no documented indications that the patient was not at or near his baseline functional status and/or his maximum level of functional potential. At the same time, there were no indications that further rehabilitative care could not be provided in the community setting with home care services and custodial level assistance. From the stand point of his functional rehabilitation, there were and are no indications that skilled nursing facility level care was or is medically necessary from 8/22/2018 forward.Final Result: The reviewer determined that the requested services were not and are 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 & 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: Overturned

A 46-year-old female enrollee requested authorization and coverage of laparoscopic adjustable banding for the treatment of morbid obesity.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested surgery is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization for Cosentyx. The submitted documentation does not support the medical necessity of the requested medication. This patient has tried and failed treatment with topical steroids and ultraviolet light therapy. The Health Plan has denied the request as not medically necessary because the patient has not failed one of the preferred oral agents, including methotrexate, cyclosporine, or acitretin. As there are no documented contraindications to the use of methotrexate or acitretin in the patient, the request for coverage of Cosentyx should be denied as not medically necessary given the availability of alternative, preferred agents that have not been tried.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: Medical Necessity
Decision: Overturned

The patient is a 21-year-old female with debilitating chronic pelvic pain since 1999. She has had multiple gynecologic surgeries for diagnosis and palliation without success. She has been treated with a GnRH medication for endometriosis. She has had a negative urologic and GI workup. She has been managed pharmacologically by a pain specialist with only limited relief and has also had trigger point injections, which were not effective. She was evaluated at a pain management clinic where she was diagnosed with myofascial pain syndrome and then referred for pelvic floor physical therapy (pelvic floor therapy). She continued pelvic floor therapy for approximately six months. The patient initially seemed to respond to the therapy, but more recently has not responded, apparently due to an exacerbation of her depression. A request has been made for continued pelvic floor therapy. The Health Plan has denied the request citing lack of medical necessity.This is a very complex case involving a very complicated patient. The American College of Obstetrics and Gynecology Practice Bulletin states that observational studies suggest that various physical therapy modalities are effective, e.g., manual therapy of trigger point in the pelvic floor showed improvement of pain in 65-70% of cases. Although this data is extracted from urologic studies, which were uncontrolled, and nonrandomized, the ACOG does recommend physical therapy as an option for the treatment of chronic pelvic pain.Review of the submitted records indicates the patient has received extensive workup and treatment for any gynecologic condition that could cause chronic pelvic pain (endometriosis, adhesions, etc.). Given the absence of other treatment options and the patients initial response to pelvic floor therapy, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. The patient should resume pelvic floor therapy with re-evaluation by her gynecologist after three months of therapy. In addition, her depression should be addressed and effectively treated. The patient should also continue to see her pain management specialist for pharmacologic treatment.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for weekly individual therapy. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 2. The patient had some risk of harm, due to recent concerning behavior online. The records did not indicate suicidal or homicidal ideation.In terms of functional status, the records support a score of 2. The documentation noted that the patient was high functioning academically with good social skills. The patients functioning was somewhat compromised due to symptoms of social anxiety and panic. With regard to comorbidity, the records support a score of 2. The patient had minor comorbidity, due to the presence of some depressive symptoms. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a mildly stressful environment due to her parents being divorced and splitting her time between the households, and some struggles with her stepfather.With regard to level of support of the recovery environment, the records support a score of 2 due to her parents efforts to arrange treatment for patient and their participation in treatment. In terms of resiliency and treatment history, the records support a score of 2. The patient had significant resiliency and/or response to treatment as she reported stopping concerning online behavior and positive self-esteem. With regard to treatment acceptance and engagement, the records support a score of 2. The patient demonstrated constructive engagement. Thus, the patient has a total score of 15. In this case, the recommended level of care is low intensity community-based services. This is consistent with the level of care that the patient is requesting. Therefore, weekly individual therapy is medically necessary for the treatment of this patient. 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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. Findings:  The physician reviewer found that