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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with alopecia areata universalis. The provider noted that the patient had a history of alopecia areata totalis, which progressed to alopecia areata universalis. Physical examination findings included sparse inferior eyelashes on one-third of the outer corner of the patients left eye. The patient has been treated with Anthralin cream, Rogaine foam, and intralesional eyebrow injections. The patient has requested authorization and coverage for bimatoprost 0.03% eyelash solution. The Health Plan denied the request and reported that the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether bimatoprost 0.03% eyelash solution is medically necessary for the treatment of the patients medical condition. Reasearchers reported, Eyelash and eyebrow hypotrichosis is a common sign of alopecia areata (AA) totalis or universalis. This may cause decreased protection to the eyes and be cosmetically detrimental for patients. The authors noted, In December 2008, the U.S. Food and Drug Administration (FDA) approved 0.03% bimatoprost solution (Latisse)for increasing eyelash length, thickness and darkness in patients with hypotrichosis of the eyelashes, or persons who desire lengthy eyelashes. The authors concluded, We observed an acceptable response in 43.24% of patients with bilateral eyelashes AA using 0.03% bimatoprost ophthalmic solution. The medical evidence supports the requested medication in this clinical setting. Therefore, bimatoprost 0.03% eyelash solution is medically necessary for the 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 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 authorization and coverage for Euflexxa injections into the right knee. Findings:  The physician reviewer found that the records document a history of chronic right knee pain associated with stiffness due to advanced arthritis. The current medical literature pertaining to viscosupplementation reveals mixed results. 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 does not support viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected patients with limited treatment options. This patient has benefitted from viscosupplementation in the past, and the alternative is a total knee arthroplasty. There is sufficient support for the requested services in this clinical setting. Therefore, Euflexxa injections into the right knee are 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 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

The patient is a 53-year-old female with long-standing knee pain. She has attempted physical therapy, acupuncture, and home exercises and continues to have persistent pain. She is seeking an MRI of her knees. The Health Plan has denied authorization for the requested MRI.Based upon the patients history and current condition, the requested MRI is medically indicated. The patient has attempted conservative treatment without success. There are a multiple number of ailments that could be responsible for the cause of her pain  all of which could be identified with an MRI. In addition, the patient may require surgical intervention but an MRI is needed to assist in determining the cause of the patients pain. Therefore, I have determined the requested MRI is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested for Orthovisc injections for treatment of her left knee arthritis. Findings:  The physician reviewer found that the evidence supporting viscosupplementation in osteoarthritis is limited at best. A recent Agency for Healthcare Research and Quality (AHRQ) guideline does not support this treatment. There is a lack of evidence in the peer-reviewed medical literature, supporting multiple series of injections as therapeutics. There are other effective treatments for relatively young patients with knee arthritis. They include osteoectomy, partial joint replacement, and cortisone injections. These options have been proven to be more effective in the available peer-reviewed medical literature.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:The patient has requested authorization and coverage for Nuplazid. Findings:  The physician reviewer found that Pimavanserin (Nuplazid) is the first U.S. Food and Drug Administration (FDA) approved atypical antipsychotic drug indicated for the treatment of hallucinations and delusions associated with Parkinsons disease psychosis. Pimavanserin exhibits a unique pharmacological profile with nanomolar affinity at serotonin 5-HT2A and 5-HT2C receptors. Functionally, it acts as a potent inverse agonist at 5-HT2A receptors, with selectivity over 5-HT2C receptors and no appreciable activity at other neurotransmitter receptors. Behavioral studies found that pimavanserin reversed impaired behaviors in animal models predictive of antipsychotic activity, and with no impairment of motor functions. The mechanism of action pimavanserin might contribute to its unique psychopharmacological properties in the improved treatment of Parkinsons disease psychosis. In this case, the patient has been treated with and failed treatment with Seroquel in 2013 and had a positive response to Nuplazid. Given these findings, the requested Nuplazid is supported as medically necessary for treatment of this patients Parkinsons disease and psychosis. 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an encephalomyosynangiosis procedure, placing a sternomastoid muscle flap on the posterior part of the brain. The treatment option for Moyamoya is generally surgical, with surgical options including direct and indirect cerebrovascular bypass. while surgical revascularization does not significantly change the underlying pathogenic mechanisms, it plays a pivotal role in the management of patients with Moyamoya disease, allowing for a decrease in the risk of ischemic and hemorrhagic complications. In this case, the patient has a diagnosis of Moyamoya and is status post bilateral external carotid to internal carotid system (EC/IC) bypasses. The records document a notable stenosis at the anastomosis on the right side along with a perfusion deficit, and a history of transient ischemic attacks (TIA). Given that this patient has progressive symptoms possibly related to hypoperfusion from stenosis at her previous direct bypass site, the requested service is medically indicated. Therefore, an encephalomyosynangiosis procedure, placing a sternomastoid muscle flap on the posterior part of the brain, 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.
Appeal type: Experimental/Investigational
Decision: Overturned

A female enrollee requested digital breast tomosynthesis  for medical  evaluation of her risk for breast cancer.   Findings:  Three physician reviewers found that in this particular patient, she has had a prior mammogram which noted dense fibroglandular breasts. This was again noted on the most recent mammogram. Digital breast tomosynthesis is rapidly becoming a standard tool in this clinical setting. Consistent with these findings, breast tomosynthesis was likely to have yielded additional data helpful in evaluating this patients medical condition beyond that expected with standard therapies.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a neurology consultation. Findings:  The physician reviewer found that the records provided for review document that this patient has a chronic medical condition and is frustrated with her level of pain. Despite being treated with multiple medications, the patient continues to have severe pain including worsening pelvic floor pain. In light of the patients chronic condition, the patient should be evaluated by a neurologist. Furthermore, seeking additional medical care or another opinion for the patients worsening pain is indicated given her lack of adequate pain management at this time. Thus, the requested neurology consultation is supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested referral is medically necessary for evaluation 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 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: Overturned

The parent of a two-year-old male enrollee has requested for individual speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that research from Gallagher and Chiat provided data on speech and language interventions for 24 preschool children with specific language impairment. The authors reported statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an eight-month period when compared to patients who received no intervention or nursery-based intervention. This patient continues to display delays in expressive and receptive language skills. Based on the foregoing discussion, the requested speech therapy is therefore medically necessary in the treatment of this patients medical condition and should therefore be approved.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a 42-year-old female with neck and shoulder pain, status post motor vehicle accident who has been diagnosed with cervicalgia, cervical spasm, and cervical radiculopathy. The patient has requested authorization and coverage for Botox injections for treatment of her neck and shoulder pain. The Health Plan has determined the requested therapy is not medically necessary.I agree with the Health Plans denial. This patient does not meet the indications for treatment with Botox injections. There is no class I evidence to support the use of Botox injections in non-specific pain syndromes status post motor vehicle accidents, and non-specific muscular pain or spasms. Thus, there is insufficient evidence that Botox injections are likely to benefit the patient. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested Harvoni for medical treatment of her hepatitis C.  Findings:  Three physician reviewers found that the submitted documentation supports the medical necessity of the requested medication in this clinical setting.  According to the recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, patients with prior liver transplant are highest priority for treatment of hepatitis C.  For patients with hepatitis C, genotype 4 and prior transplant, the guidelines recommend Harvoni with ribavirin for 12 weeks.  In sum, the requested medication Harvoni is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The representative of a 16-year-old male enrollee has requested for his treatment for Behavioral Assessment for treatment of the enrollees attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and reactive attachment disorder (RAD). Findings:  The physician reviewer found that there was a significant risk of deterioration at a lower level of care. As noted in the Child and Adolescent Level of Care Utilization System (CALOCUS), there are several dimensions to consider such as presence of significant co-morbid medical conditions, co-morbid psychiatric disorders and level of functional impairment. All told, the patient required the level of intensity provided at the Aspen Institute and was not appropriate for a lower level of care during the period at issue.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old female enrollee has requested for an abdominoplasty for treatment of her excess skin condition. Findings:  The physician reviewer found that the patient does not have medical record documentation over time of skin infections in the abdominal fold, and photographs documenting cellulitis, ulcerations or rashes have not been submitted. The medical records do not provide any documentation in the form of PCP or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either 1) never responded to topical therapy or 2) despite initial response, have recurred and caused significant functional impairment.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for (1) Tacrolimus ointment 0.1% and (2) Tacrolimus ointment 0.1%. Elmets and colleagues note that psoriasis is a chronic condition and that topical medications are the most common agents in the treatment of mild to moderate psoriasis. The authors further note that in a study of 167 patients with facial and intertriginous psoriasis, treatment with tacrolimus 0.1% resulted in clearing for 65% of patients after eight weeks of therapy. Given that topical therapy is often the first-line treatment for limited areas of involvement, especially in children, due to safety concerns with systemic drugs in this population, the medication at issue was medically indicated. Therefore, (1) Tacrolimus ointment and (2) Tacrolimus ointment 0.1% was and is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was and 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:  The enrollee has a history of hypertension.  She has been taking generic losartan but became concerned about contamination and is therefore requesting brand-name Cozaar.Final Result: The reviewer determined that the medication at issue is medically necessary for treatment of the patients condition. Therefore, the health plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in Cardiovascular Disease and is actively practicing.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested a panniculectomy for the treatment of her excess abdominal skin and back pain. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that the patients lower back and leg pain is caused by piriformis syndrome and is unrelated to her excess abdominal skin. There is no documentation in the medical record of skin irritations, infections, or pigment changes related to the abdominal pannus. Thus, no medical indication for panniculectomy has been established.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 41-year-old male with a past medical history of anemia who was admitted through the emergency department of a hospital in October 2005. He presented status post syncopal episode with vomiting, diaphoresis and loss of consciousness. Previously, there was no evidence of seizure activity. The patient had apparent seizure activity in the ER. The patient was admitted and evaluated by gastroenterology/hematology. Endoscopy revealed deformity in the pyloric area and no active bleeding at site. A colonoscopy was negative for active bleeding. The patient also underwent a bone marrow biopsy. He received blood transfusion/IV. The patient was discharged from the hospital in October 2005. At issue in this case is whether continued hospitalization was medically necessary as of October 2005.There was no documentation provided necessitating inpatient hospitalization as of October 2005. The GI evaluation (endoscopy/colonoscopy) was completed by October 2005. No active bleeding site was identified and transfusion had been completed and the patient was hemodynamically stable. No neurology evaluation was conducted regarding the seizures. The patient underwent bone marrow aspirate for issues related to his chronic anemia. Based on the evaluations provided for review, the patient was medically stable, and appropriate for discharge in October 2005. There was a history of alcoholism but there was no requested treatment or clinical evidence of withdrawal. A full workup of the patients presenting symptoms was completed by October 2005.  Therefore, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a power wheelchair for treatment her severe cervical stenosis at C4-7.  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested power wheelchair. Edwards and Mccluskey state The benefits of power-mobility devices are reported to include improved quality of life, an increased sense of freedom and improved self-esteem. In this case, the patient has had impaired functional mobility for which she has been at a skilled nursing facility for over one year. A manual wheelchair allows mobility in her room. However, there are no medical notes documenting a rationale for a power wheelchair. In addition, the patient resides in a facility where assistance is available and additional surgeries/treatments are possible to improve her mobility status. As such, there is a lack of support in the documentation submitted for review establishing the medical necessity for a power mobility device at this time. Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 21-year-old female has requested coverage for  past inpatient acute psychiatric level of care services provided for treatment of depression.  Findings:  The physician reviewer found that in this particular case, the patient had a significantly increased anxiety titer and depressive burden. However, the documentation provided was inconsistent with grave disability due to mental illness. The patient was well nourished and medically cleared. She was not paranoid, psychotic, or delusional. Her thought process was linear and her judgment was fair. She denied suicidal and homicidal ideation and posed no imminent threat to self or others. Her suicide risk assessment revealed an assessment of low immediate risk with recommended disposition of discharge to home. She had good local peer support and a supportive family, despite geographic separation. She had recently resumed psychotropic medications in the outpatient setting and the complexity of the regimen did not necessitate inpatient care. There was no supporting documentation or clinical rationale illustrating that treatment in a less restrictive level of care, such as crisis intervention services, increased frequency of clinic visits, or intensive outpatient programming, would have been inadequate to effectively treat the patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old female enrollee has requested for a chest CT angiography for evaluation of her coronary artery disease. Findings:  Three physician reviewers found that chest CT angiography would be unlikely to reveal a normal coronary anatomy free of disease. The standard medical treatment of this patient would be to either maximize her medical treatment for angina or coronary artery disease or proceed with cardiac catheterization towards a revascularization strategy.