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

A 64-year-old female enrollee has requested for mental health acute inpatient treatment level of care for treatment of her bipolar disorder and dementia. Findings:  The physician reviewer found that inpatient psychiatric care is aimed at decompressing the acute exacerbations of episodic serious mental illness.  In this patients case, the documentation demonstrates the medical necessity of mental health acute inpatient treatment level of care for part of the stay.  However, the medical records fail to justify the necessity of continued inpatient acute care services. There were no medication changes or acute medical issues.  There was no suicidality, homicidal ideation, aggression, or disruptive behavior.  Ancillary services and nursing notes indicated that the patient required much redirection and displayed intrusiveness, but responded well to positive support.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollees parent has requested coverage for psychotherapy two to three times per month with a therapist that specializes in treating children with chronic illness and pain. A review of the pediatricians records indicates enrollee complaints of abdominal pain and vomiting, which he has had intermittently over the past year. His mother reports daily emesis with these episodes. He was diagnosed with eosinophilic esophagitis (EoE) that was initially treated with viscous budesonide, was doing well but he started having abdominal pain again. In an assessment note, the pediatric gastroenterologist indicates the vomiting may have a volitional/psych component. Recommendations on this date included anxiety evaluation and management. History notes seven weeks of daily vomiting, with emesis to 20+ times a day. Pain is several times a day and at bedtime. Enrollee is missing school.  Many stressors are noted, some fear of dying with family losses and generalized anxiety. Enrollee is hungry, eats, but vomits and is losing weight. Social history indicates anxiety, deaths in family and fear of dying. Etiology unclear; consider anxiety disorder; appears to have a volitional component. Another note indicates possibility ongoing vomiting is psychosomatic especially since biopsies are essentially normal. Parents report enrollee was depressed and in pain even though vomiting started to subside. Recommendations from the enrollees providers for treatment include anxiety evaluation and management.  There is sufficient documentation in the record of functional impairment and distress related to the enrollees severe medical illness, which impacts his life significantly on a daily basis. The medical literature indicates the treatment of anxiety disorders in children and adolescents usually involves a multimodal approach. Comprehensive treatment includes consideration of education of the parents and the child about the specific anxiety disorder, consultation with school personnel and primary care physicians, behavioral interventions, psychodynamic psychotherapy, family therapy, and pharmacotherapy.  Children with anxiety disorders manifest a spectrum of symptomatology ranging from mild worry and distress to overwhelming, incapacitating anxiety that greatly interferes with functioning. In practice, child and adolescent psychiatrists usually use a combination or integration of several approaches in treating a child or adolescent with an anxiety disorder.Final Result: The reviewer determined that the requested service is medically necessary for thetreatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in Psychiatry and 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 46-year-old woman with a long history of back pain who is status post lumbar fusion. The patient is followed by a pain management specialist. The patient has been receiving physical therapy and takes Norco and Duragesic for pain management. In addition, the patient has used Actiq. The patients request for authorization of Actiq has been denied by the Health Plan.The Health Plans denial is medically reasonable and appropriate. The patients provider has indicated that the patient has used Norco for breakthrough pain in place of Actiq. While Actiq has been approved by the Food and Drug Administration (FDA) for pain due to cancer, it has not been approved by the FDA for back pain or non-malignant conditions. Furthermore, review of the submitted information indicates that the patients pain can be controlled with maximization of long-acting medications and with other short-acting medications as needed, such as Norco. Therefore, I have determined that the requested medication 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 29-year-old female enrollee has requested for Botox injections for treatment of her refractory migraine.   Findings:  Two physician reviewers found that literature  shows that Botox can be beneficial for individuals with chronic headache including those with medication overuse. This patient has reportedly had benefit with prior Botox therapy, and worsening headaches when the Botox has worn off. As she has failed multiple standard preventive regimens, and has had benefit in the past with Botox,
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old female coverage for lumbar spinal fusion surgery at 2 levels, or 1 level in the alternative for treatment of her grade 5 tears of the L3-4 and L4-5 discs.   Findings:  The physician reviewer found that based on review of the available records, this patient has chronic low back pain and has developed an L5 radiculopathy as well as progressive symptoms with weakness and decreased sensation as documented by the provider. The patients discography is not conclusive or helpful given her pain response at all three levels. In fact, the discographer even noted that he did not have an adequate control level. Thus, the data with low recorded pressures is considered less reliable. Since this patient has no evidence of instability, spondylolisthesis, angulation, fracture, tumor or infection, she does not meet criteria for fusion according to Bambakidis and colleagues or the Milliman Care Guidelines. Since she has left L5 radiculopathy due to lateral recess stenosis and disc protrusion/herniation the requested decompression is medically necessary for management of her condition. However, the patient does not meet the criteria for fusion as noted by Bambakidis and colleagues. Therefore, the requested fusion has not been shown to be medically necessary in this patients care.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old female enrollee has requested 1.5% Pennsaid Gel for treatment of her osteoarthritis.  Findings:  The physician reviewer found that the submitted documentation fails to support the medical necessity of the requested medication for the treatment of this patient.  The medical records do not demonstrate an indication for the use of 1.5% Pennsaid Gel in this patients case.  The clinical records do not provide details regarding the efficacy of the requested medication for this patient.  Additionally, medical records pertaining to the initiation of this medication were not submitted for review.  There were no laboratory studies provided to document this patients renal function.  The clinical documentation does not provide details regarding the stated diagnosis of osteoarthritis.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sclerotherapy for treatment of the enrollees varicose veins of the right leg. Findings:  2/3 of the physician reviewers found that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, there is no superficial reflux, and there are large symptomatic varicose veins. As such, it is medically reasonable to address those veins. This is especially true for this patient who is symptomatic. The proposed services are the standard of care in this clinical setting. All told, the request for sclerotherapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the requested services are 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: Physician reviewer number one is board certified in interventional radiology with sub-specialty certification in vascular radiology 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.Physician reviewer number two is board certified in vascular 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.Physician reviewer number three is board certified in vascular 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: Experimental/Investigational
Decision: Upheld

The parent of a male enrollee requested platelet rich plasma injection for medical treatment of the enrollees torn labrum. Findings:  Three physician reviewers found that the current medical literature indicates that conservative care should be carried out prior to a surgical intervention. The documentation provided does not indicate that the patient had undergone any physical therapy, medications, or injections to attempt and alleviate his pain and symptoms prior to opting to undergo surgery. There was no indication that the patients condition was severe enough to require immediate surgery without undergoing conservative care. Also, the current medical literature does not support the use of platelet rich plasma injections intra/postoperatively and states that there is little evidence to support their efficacy. Based on the documentation provided, the patients diagnosis, and the current medical literature, the platelet rich plasma injection was not likely to have been more beneficial for the patients medical condition that any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 45-year-old female enrollee has requested a follow-up magnetic resonance imaging (MRI) of the breast for evaluation of her atypical ductal hyperplasia. Findings:  Two physician reviewers found that the issue in this case is not whether the patient is a candidate for a screening exam, which would be based on her lifetime risk. Rather, this case concerns whether a follow-up MRI is appropriate based on the patients BI-RAD 3 category level of risk. Based on American College of Radiology guidelines, a BI-RAD 3 category (Probably Benign Finding) warrants short-interval follow-up. As with mammography, six-month surveillance is appropriate in this setting. It is also appropriate to follow this patient with the same modality that revealed the initial findings (MRI).
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for psychiatric emergency services. Based upon the evidence submitted for review, the patient was assessed psychiatrically and medically during his admission. The patient was deemed to have no safety risk. During the assessment and throughout the patient's residential treatment, the patient did not receive treatment for a psychiatric emergency medical condition. The patient was not assessed as, nor did he suffer from, a psychiatric emergency medical condition. He was not self harming, suicidal or homicidal and therefore not a danger to himself or others. He was cognitively intact, and showed no immediate risk of withdrawal as he had just completed a two week detoxification program. Given this, his symptoms would be considered post-acute withdrawal symptoms. Management of the patients medications could have been provided on an outpatient basis. All told, the patient was not experiencing a psychiatric emergency medical condition during the period at issue. Final Result: The reviewer determined that the patient did not receive psychiatric emergency medical services during the period at issue. 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: Experimental/Investigational
Decision: Upheld

A female enrollee requested corneal collagen cross linking for medical treatment of her keratoconus.  Findings:  Two physician reviewers found that the patients corrected visual acuity is fairly good in both eyes. Thus, before recommending cross linking therapy, contact lens fitting should be attempted. There are also corneal surgical procedures such as INTACS or penetrating keratoplasty that may improve this patients health condition. Accordingly, the requested corneal collagen cross linking is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier for 12 weeks. Findings:  The physician reviewer found that according to the most joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent . AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment . For these reasons, treatment with Zepatier for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation (TMS) services.  TMS is currently indicated for the acute phase of major depression. Perera and colleagues noted that daily left prefrontal TMS had substantial evidence of efficacy and safety for treating the acute phase of depression in patients who were treatment resistant or intolerant. In this case, the patient has severe depression and has failed trials of Cymbalta, Effexor, and Prozac. Given the severity of the patients symptoms and functional impairment, TMS was and is clinically indicated. Therefore, TMS services were and are likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the transcranial magnetic stimulation (TMS) services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the transcranial magnetic stimulation (TMS) services were 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: Physician reviewers 1, 2, and 3 are board certified in psychiatry 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

A 51-year-old male enrollee has requested for an integrated weight change program for treatment of his morbid obesity. Findings:  The physician reviewer found that morbid obesity is widely recognized as a disease process with significant comorbidities. Treatment for this condition is clinically indicated and participation in the integrated weight change program is a reasonable alternative.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old female enrollee has requested delivery via a water birth for treatment of her anxiety.  Findings:  The physician reviewer found that in this case, the patient indicates she is seeking the option of a water birth to reduce her anxiety.  As noted above, there are a variety of other interventions that can be employed to help reduce maternal anxiety during the delivery process. Further, hydrotherapy (water immersion during labor) can help reduce anxiety and is available at most birthing centers. The is a lack of evidence demonstrating that water delivery has a measurable impact on reducing maternal anxiety or is any more effective in treating maternal anxiety than the alternatives mentioned above. Further, although the medical literature does not indicate that delivery in water significantly increases adverse perinatal outcomes, one survey of outcomes of 4,032 births in water revealed two cases of water aspiration and five cases of snapped umbilical cords, which appear to be risks of this method of delivery. This patient has the option of delivery in a low-intervention facility that has incorporated many protocols to reduce anxiety and foster a patient and family-centered birth experience. Hydrotherapy appears to be available to her in that setting. Given the availability of alternative methods of addressing the patients anxiety as well as a lack of substantial medical literature demonstrating a significant correlation between water birth and reduced anxiety, the requested services are not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old male enrollee has requested for a magnetic resonance imaging (MRI) scan of the lumbar spine for evaluation of his low back pain. Findings:  The physician reviewer found that the MRI study is the proper diagnostic study for the clinical diagnosis present in the record (i.e., intervertebral disc herniation). A further reason to proceed with MRI study of the lumbosacral spine is that there is a high risk of iatrogenic drug dependency with prescription of opioids. There is documentation that the dose levels have been increased in this patient. The information obtained through MRI should allow a more focused and effective conservative management program, as well as ruling in or out a number of specific lesions, possible pain generators for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for morphine sulfate 200 mg extended-release tablets, three times daily for treatment of the enrollees pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. The patient is taking a high dose of morphine. The risk of opioid-related overdose is dose dependent, and this patient is at increased risk of overdose. There is no documentation submitted that demonstrates a multidisciplinary approach to dealing with this patients pain. There is a lack of documentation of nonsteroidal anti-inflammatory drugs or anticonvulsant medication trials, cognitive behavioral therapy, physical therapy, chiropractic therapy, epidural steroid injections or surgery consultation. There is no documentation of urine toxicology screening in the submitted documents.  The evidence supporting the use of this high dose of opiates for non-malignant chronic pain is weak, and the medical evidence supports tapering the medication in this setting. The current medical evidence does not support the requested medication in this patients case. 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Tibsovo (ivosidenib) 500 mg. The available records document that this patient presents with grade II oligoastrocytoma in left frontal region and multiple sclerosis. The patient is status post resection in 2013. Serial MRI studies have demonstrated a progression of the tumor over the long-term. The provider started the patient on the Tibsovo. As noted in the medical literature, Tibsovo is a novel medication that specifically inhibits cells that harbor an IDH-1 mutation as with most cells of an oligoastrocytoma. Per the U.S. Food and Drug Administration (FDA), Tibsovo has been approved for use in acute myelogenous leukemias with an IDH-1 mutation. The reports on Tibsovo in the treatment of patients with oligoastrocytomas is limited, but promising (Mellinghoff, et al.). For this patient, treatment with additional radiation and/or chemotherapy is not recommended due to her comorbid diagnosis of multiple sclerosis. Given these findings, the requested Tibsovo (ivosidenib) 500 mg is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in medical oncology 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.