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 Percocet 10/325 (three times a day).Findings:  The physician reviewer found that the medical literature does not support the medical necessity of the requested medication regimen in this clinical setting. The Argoff review article noted specifically that for chronic non-cancer pain, short acting and long acting opioid have been found to be effective. However, the review also noted that therapies should be tailored to the individual patient. In the Nicholson article, it was noted that opioid doses should be titrated according to agent-specific schedules to maximize pain relief and maintain tolerability. In this patients case, the documentation shows that recent visits with her treating provider noted some success with tapering of Percocet. Progress notes dated 8/10/16 noted that the patient was drinking more fluids and feeling better overall.  At that time, the patient was on Percocet 7.5 mg.  Therefore, a higher dose of Percocet is not medically indicated for treatment of this patient. Instead, continued weaning of Percocet is medically appropriate.Final Result: The reviewer determined that  the requested medication regimen is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ganglion impar block.The patient has chronic pelvic pain, and the records noted pain in the rectum, vagina, and coccyx areas. Her pain is not localized. Therefore, treatment with ganglion impar block is likely to be inadequate. Coccydynia has been treated with ganglion impar block. The ganglion impar is a midline sympathetic ganglion located just anterior to the upper coccyx. Support for this treatment has only been demonstrated through case series. Medical literature evaluated a series of 22 patients with persistent coccydynia that failed to respond to initial conservative treatments. The researchers found that ganglion impar injection successfully provided greater than 50 percent relief in 82 percent of patients, with a mean duration of relief of six months. Although these results are promising, this treatment is not standard of care. At this time, further trials performed at a larger scale are needed. Therefore, the requested ganglion impar block is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested radiofrequency neurotomy (ablation) for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. The medical literature is clear that a diagnostic medial branch block is supposed to be performed prior to radiofrequency ablation; specifically, using a pain diary to verify when the local anesthetic wore off. In the submitted documentation, the provider does not document a pain diary for a medial branch block prior to the previous radiofrequency ablation. Moreover, based on the notes from the patients prior radiofrequency ablation procedure, it appears the patient would obtain the same relief from a steroid injection alone without being subjected to increased risk from radiofrequency ablation. The records also do not indicate a prior failure from facet injections nor is there any documentation as to having the test redone to ensure the correct sites are still being treated. The submitted medical records do not mention an increased functional benefit from baseline and no decrease in perceived pain from baseline with the patients previous radiofrequency ablation procedure. Instead the records indicate that the previous radiofrequency ablation did not help her pain in her forearms and hands.  Furthermore, the documentation demonstrates that after the first radiofrequency ablation, the patients use of opioid medications has increased from very minimal to much higher doses. Moreover, the patients surgeon had recommended against a repeat of the procedure and instead discussed other treatment options that have not yet been attempted by this patient. Therefore for all these reasons, the requested radiofrequency neurotomy (ablation) is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested procedure 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 management 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 reimbursement and prospective authorization and coverage for Botox injections. The patient has been diagnosed with migraine headaches associated with visual disturbances. Prior treatment with Propranolol caused side effects that required an emergency room treatment for hypotension and bradycardia. The provider noted that the patient has been unable to tolerate other abortive medications for headache management. The patient reported that treatment with Zoloft has minimized her headaches, but not completely resolved them. The current peer-reviewed medical literature supports the use of Botox for the management of migraine headaches that have been refractory to other traditional therapies. Researchers concluded that the available clinical trial data has demonstrated that Botox is an effective and well-tolerated treatment modality for the prevention of chronic migraine, especially for patients who have previously failed to respond to or are intolerant of commonly prescribed oral prophylactics. Given these findings, the Botox injections were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 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: Experimental/Investigational
Decision: Upheld

A 49-year-old female enrollee requested authorization and coverage of high-dose chemotherapy and autologous bone marrow transplant. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees metastatic breast cancer.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested surgery is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old male enrollee has requested residential treatment center services for treatment of the enrollees substance abuse and depression.   Findings:  The physician reviewer found that based upon the documentation provided, the alternate level of care recommended by the Health Plan would have been medically appropriate for this patient. The patients presentation on admission and throughout the course of his RTC stay does not support a need for the intensity of services of an RTC level of care. The records do not demonstrate the patient posed a risk to self or others. Additionally, withdrawal symptoms or other medical issues are not documented in the clinical records. While the patient had a history of family conflict, his parents were noted to be supportive of his recovery. Further, the services recommended by the Health Plan included family therapy. All told, the medical necessity of RTC level of care is not established. The evidence demonstrates the patient could have been safely and effectively treated at a less intensive level of care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transfer to a higher level of care (from a skilled nursing facility (SNF) services to inpatient hospital services). The available records document that this patient has multiple chronic medical problems and ongoing mobility challenges. The provider reported that the patient has been chronically noncompliant with her care. There is a lack of evidence that the patient has any active, acute medical issues that could not be addressed in an ambulatory setting and requires acute hospitalization for further evaluation or treatment such as acute infection, congestive heart failure, exacerbation of chronic obstructive pulmonary disease, a fall-related acute injury, or alteration in consciousness. The available records do not indicate that the patient has any acute functional deficits requiring intensive multidisciplinary rehabilitation services consistent with the acute inpatient rehabilitation setting of care. Therefore, the requested transfer to a higher level of care (from a SNF services to inpatient hospital services) is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested mental health services on an emergent or urgent basis. Findings:  The physician reviewer found that at issue in this case is whether the enrollee was experiencing a psychiatric emergency medical condition. A psychiatric emergency medical condition is defined as a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders the patient as being either of the following: (A) an immediate danger to himself or herself or others  or (B) immediately unable to provide for, or utilize, food, shelter, or clothing, due to the mental disorder. Urgently needed services are defined as those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the plans service area. In this case, the patient did not meet criteria for a psychiatric emergency medical condition as he did not pose an imminent danger to self or others and was able to appropriately utilize food, shelter and clothing. Based on the patients presenting symptoms, he was not experiencing a psychiatric emergency medical condition. However, the patients decision to seek medical attention was consistent with the actions of a prudent layperson. The patient urgently needed services to prevent a serious deterioration resulting from his existing condition, bipolar disorder, which represents a severe mental disease that has poor outcomes. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would reasonably believe he needed urgent medical attention to prevent serious deterioration of his health. Thus, the services meet prudent layperson criteria for urgent care.  Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for urgently needed services. 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hip resurfacing. The submitted documentation supports the medical necessity of the requested services. This patient presents with persistent and worsening right hip pain with functional limitations in weight-bearing activities and activities of daily living. The records indicated he had normal bone quality and shape. He had failed conservative treatment, including activity modification, physical therapy, and medications. A hip resurfacing procedure has been recommended over total hip arthroplasty based on the patients age and activities. The current peer-reviewed literature supports hip resurfacing in this clinical setting. Therefore, the requested hip resurfacing 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 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: Urgent Care
Decision: Overturned

A 58-year-old male enrollee has requested for ophthalmology services indicating the services at issue were required on an emergent basis. Findings:  The physician reviewer found that choroidal neovascularization (CNV) is the formation of new blood vessels in the choroidal layer of the eye. A sudden deterioration of vision may result if these fragile new vessels cause hemorrhage.  Left untreated, CNV can cause permanent loss of central vision. Silva and colleagues (2008) have established that intravitreal injections of bevacizumab (Avastin) are safe and effective for myopic CNV. Currently, no consensus exists on the timing of Avastin injections in this condition. At this time, the exact timing of Avastin injections in myopic choroidal neovascularization is a matter of clinical judgment. In most cases, the treating provider would likely elect same day treatment of acute macular hemorrhage due to myopic CNV. In this setting, most clinicians would hesitate to transfer care if the source of hemorrhage has not been established. Thus, a prudent layperson in this situation would reasonably expect serious impairment of vision without continued medical attention from the treating provider. Thus, the patients symptoms met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned

A 35-year-old male enrollee has requested for a stand-up magnetic resonance imaging scan and electrodiagnostic studies including nerve conduction study with electromyography for evaluation of his neurological pain and extremity pain and numbness.  Findings:  The physician reviewer found that no evidence has been provided that the patient has experienced any significant changes in his symptomatology since the previous NCV and EMG testing. As such, there is no evidence from which to conclude that repeat NCV with EMG is likely to result in clinically useful information that will alter the management of this patients condition. Thus, I have determined that the requested repeat electrodiagnostic testing is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the services at issue were not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient showed no withdrawal symptoms, and was not a danger to self or others. The patients highest CIWA was 8. The patient was cognitively intact and was not gravely disabled. There were no emotional, behavioral, or cognitive symptoms requiring monitoring and supervision in the residential setting. The patient was not psychotic or manic. The patient was medically and psychiatrically stable. The patients elevated liver function tests (LFTs) were not of the severity to require 24-hour monitoring. There were no dosage changes to her Lexapro and Lamictal, the only medication changes were a dose of Toradol and the addition of Vistaril. The patients eating disorder was mild as only the patient had some urges but did not demonstrate behaviors. The patient was learning and solidifying coping skills. The patient was motivated, cooperative, and participating in all aspects of treatment plan. Thus, residential treatment center level of care was not medically necessary, and the patient could have been safely treated on an ambulatory basis.  Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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 23-year-old female enrollee has requested for services from a pediatric cardiologist who specializes in caring for patients with adult congenital heart disease/polysplenia and who is also an electrophysiologist for treatment of her congenital heart disease. Findings:  The physician reviewer found that Centers of excellence are comprised of pediatric cardiologists, pediatric cardiology surgeons, adult cardiologists with specific training and experience in congenital heart disease, electrophysiologists with specific training and experience in adult congenital heart disease, and associated nursing, counseling, and social service professionals who are all integrated to optimally provide comprehensive care for this population of patients with unique needs.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested physical therapy and occupational therapy at a skilled rehabilitation facility for treatment of her peripheral edema, peripheral vascular disease, and hepatic encephalopathy.  Findings:  The physician reviewer found that the records indicate this patient reached a functional status with ability to walk with use of a walker and ability to dress and perform self-care without hands on support. The patient does not currently require daily inpatient skilled therapy (Ward, et al). She will continue to improve in functional status if she is able to refrain from consuming alcohol. The key for her return to her previous status and improvement in her liver indices is not continued daily skilled therapy as she can receive quite adequate therapy as an outpatient (Alvarez, et al). She has no daily skilled therapy or skilled nursing needs. Continued daily skilled services are not necessary to restore or maintain function. Thus, the requested physical therapy and occupational therapy at a skilled rehabilitation facility is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old female enrollee has requested mental health outpatient therapy on an unrestricted as needed basis, in addition to her current visit frequency of once per month for treatment of the enrollees bipolar disorder and generalized anxiety disorder.  Findings:  The physician reviewer found that the frequency and duration of outpatient mental health visits should allow for safe and timely achievement of treatment goals, and should support progress toward recovery. To achieve these goals multiple factors should be taken into account including the treatment objectives, the patients preferences, and the degree of intensity indicated to monitor and address imminent risk to the patient. Initially, the frequency of outpatient visits generally varies from weekly to several times a week. In the later stages of treatment, the frequency of visits may decrease further. According to this patients records, there are two requests being made requiring review. The parent has requested unrestricted visits as needed for the patient, but the attending provider has requested 18 visits to be used at the discretion of the provider during the course of the year. The provider states that in general one visit per month may be sufficient if the patient remains completely stable, however the frequency of visits may need to be increased if the patient shows signs of deterioration, as she has done within the past year. The records suggest that having authorization for the additional visits will hopefully allow quick re-stabilization and avoid the need for more intensive services. This practice exemplifies the highest quality of outpatient care and is certainly medically necessary in this case. Moreover, this conclusion is consistent with the criteria for treatment of patients with bipolar disorder from the American Academy of Child and Adolescent Psychiatry (AACAP). The guidelines state that, pharmacological interventions require baseline and follow-up symptom, side effect and laboratory monitoring as indicated. Thus, it is purely a matter of clinical judgment on the part of the provider to decide the frequency of visits. Consistent with these recommendations, the 18 visits requested by the provider are appropriate and medically necessary.