Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laceration repair of the fifth finger with the use of NeuraGen nerve guide for treatment of the enrollees laceration of right fifth finger. Findings:  The physician reviewer found that When a peripheral nerve is completely resected, no recovery of function occurs without surgical repair.  In this case, the digital nerve is a sensory nerve and the patient would not recover any sensibility in the ulnar tip of the small finger without repair. Tension on nerve repairs is detrimental and the 1 cm gap between the ends of the lacerated nerve in this case needs to be bridged surgically.  One option is to harvest a nerve autograft or vein for use as a conduit, which involves an additional surgical site and associated risks. Another option is to use a synthetic conduit such as performed in this patients case.  The medical literature notes that for digital nerve repair with a gap under 2 cm, the use of a synthetic conduit is the preferred repair technique. As such, the conduit used in this case was likely to have been effective for repair of the patients lacerated digital nerve with a 1 cm gap. Accordingly, the laceration repair of the fifth finger with the use of NeuraGen nerve guide was likely to have been more efficacious for the treatment of this patient than the available standard methods. Final Result: Two of three reviewers determined that the services at issue 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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

A 20-year-old female enrollee has requested inpatient care at a neuropsychiatric hospital for the treatment of her behavioral health problems. Findings:  The physician reviewer found that the American Psychiatric Association Practice Guidelines for patients with eating disorders, patients with inadequate motivation or support who are discharged from inpatient to partial hospitalization programs before they are clinically ready often have high rates of early relapse, greater struggles with recovery, and slower rates of progress, necessitating longer future inpatient stays. When transitioning to a lower level of care, it may be destabilizing for a patient and it is important that patients be able to transition smoothly to the next (less intensive) level of care. The guidelines also state that attainment of weight goals alone should not be the sole basis for the decision to discharge a patient from the inpatient setting, but the entire bio-psychosocial picture of the patient needs to be taken into account. Using these criteria, I find that there is clear medical necessity, based on the patients admission history and course, for the beginning dates of service in question. This is evidenced by the patient demonstrating motivation and active independent compliance with multiple aspects of the treatment program, as well as showing a realistic appraisal of her situation. However, medical necessity is absent from the remaining dated in question as the documentation does not support the need for, or show additional benefits as a result of, continued hospitalization.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old male enrollee requested authorization and coverage of a power-operated vehicle (POV). The Health Plan denied the request indicating that the requested equipment is not medically necessary for the enrollees mobility.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for readmission to acute rehabilitation, focusing on physical therapy, occupational therapy, and pain management. There is a paucity of evidence to support intensive rehabilitation interventions during the period of immobilization and weight bearing restrictions following distal lower extremity fractures (Lin, et al.; and Moseley, et al.). The focus of rehabilitation during this rehabilitation period is to acquire compensatory skills to manage functionally in as independent a manner as possible given the acute impairment and comorbid conditions. Following a unilateral ankle fracture in the absence of other significant concomitant injuries, patients who are able-bodied at baseline do not generally require inpatient rehabilitation at all as they can manage in the community with axillary crutches or a walker after discharge from the acute hospital. In the present case, the patient sustained a left ankle fracture-dislocation that required surgeries, immobilization, and non-weightbearing restrictions. The patient did not sustain any other significant documented injuries and the patients upper limb function was assessed to be intact. The patient was at a high functional level. Specifically, he required stand by assistance for transfers and ambulating 150 feet with a walker. By the completion of his acute inpatient rehabilitation course, he was at an independent to contact guard assistance level for his basic self-care and mobility. This level of function can be addressed with community-based rehabilitation, either in the home or as an outpatient. Home-based rehabilitation also provides the patient an opportunity to practice and improve his self-care skills and his mobility tasks in his actual home setting, which is more directly applicable to his functional needs than practicing these tasks in a rehabilitation facility. Given these findings, the requested readmission to acute rehabilitation, focusing on physical therapy, occupational therapy, and pain management 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medications Xanax (alprazolam) 0.5mg twice a day as needed and Norco (hydrocodone/acetaminophen) 5/325mg three times a day as needed.Federation of State Medical Boards guidelines for the Chronic Use of Opioid Analgesics state that continuation, modification or termination of opioid therapy for pain is contingent upon a clinicians evaluation of evidence of the patients progress toward treatment objectives and the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. CDC guidelines for the prescribing of opioids for chronic pain state that clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalationIn this case, the patient has not used either Xanax or Norco for two and one-half years. The patient was seen by her primary care provider recently, and she did not request or receive a prescription for either of these medications at that time. The patient was also seen by a pain management specialist, and after evaluating the patient, they did not conclude that the patient was a suitable candidate for Xanax or Norco due to her psychiatric comorbidities, including possible borderline personality disorder. The patients recent total body MRI demonstrated findings of degenerative disc disease of the neck and low back without significant canal or foraminal stenosis, therefore, these MRI findings did not reveal high grade stenosis that would be commensurate with the patients complaints. Under these circumstances, the requested medication Xanax (alprazolam) 0.5mg twice a day as needed is not medically necessary for treatment of the patients medical condition. In addition, the requested medication Norco (hydrocodone/acetaminophen) 5/325mg three times a day as needed is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denials should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty 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

A 19-year-old male enrollee has requested the prescription drug Lexapro for the treatment of his major depression. Findings:  The physician reviewer found that the Health Plans criteria for coverage of the requested medication are medically appropriate and reasonable, and the patient has not met these criteria. In addition, the medical data contained in the record is rather limited. The treating physician does not explain his rationale for the current medications that are being used, nor does he explain what about the patient made him so difficult to stabilize. The treating physician suggests the patient has become manic at times, but he does not elaborate. Although the patient is now doing well, there is no specific reason given why this improvement is linked to Lexapro, and why the use of a formulary antidepressant would not be equally effective.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the left breast and under armpit area. Medical literature notes that ultrasound is the first-line investigation before mammography, MRI or biopsy, which may be indicated for suspicious abnormalities. This patient has undergone a thorough imaging evaluation for her recurrent chest wall and breast pain. Imaging has included a left breast ultrasound and MRI studies in March 2019 and May 2019, with unremarkable findings. There has been no documented change in the patients symptom complex. The current medical literature does not support a repeat MRI in this clinical setting. All told, the requested MRI of the left breast and under armpit area is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic 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

The representative of a 20-year-old female enrollee requested reimbursement for partial hospitalization services the enrollee received from 6/3/03 through 6/27/03. The Health Plan denied the request indicating that the services at issue were not medically necessary for treatment of the enrollees eating disorder.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services were not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 23-year-old female enrollee has requested home lumbar traction unit, CPT code E0890 for treatment of her pain. Findings:  Three physician reviewers found that there is insufficient evidence in the medical literature to support the efficacy of traction for the treatment of low back pain.  Although it is used as empiric therapy in clinical practice, there is a lack of evidence demonstrating that it is more beneficial for the treatment of low back pain than other standard available interventions.  All told, the superior efficacy of the home lumbar traction unit has not been established in this clinical scenario.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient behavioral health treatment has requested reimbursement for inpatient behavioral health treatment. Findings:  The physician reviewer found that based on the clinical documentation provided, the inpatient behavioral health treatment provided was medically necessary for treatment of the patients medical condition. The patient remained symptomatic during the dates in question. The patient had unstable vital signs as evidenced by the documentation of elevated blood pressures and administration of as needed medication for hypertension.  In addition to the scheduled blood pressure medication, the patient received doses of as needed clonidine for hypertension. The patient was documented as having withdrawal symptoms and depressed and anxious mood. The patient received several doses of as needed lorazepam and one dose of as needed lorazepam for persistent withdrawal symptoms. The patient was documented by nursing staff as endorsing suicidal ideation with urges to self-harm.  The psychiatrist documented that the patient had depressed and anxious mood with poor grooming and endorsed urge to self-harm. The factors that support continued stay at the inpatient level of care in this patients case include documentation of active withdrawal symptoms, unstable vital signs, suicidal ideation, failure of prior treatment, and high risk of relapse as evidenced by admission in July followed by relapse upon discharge. The patients clinical status, in addition to current medical literature, support that the continued stay at the inpatient level of care was medically necessary for treatment of the patients medical condition. Final Result: The physician reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a consultation with a neurosurgeon for treatment of the enrollees neck mass.   The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  This patient has chronic neck pain and a neck mass.  The Health Plan has recommended a consultation with an ear, nose and throat specialist.  However, an ear, nose and throat specialist reportedly referred the patient to pain management.  The neck mass is located in the upper posterior neck.  Ear, nose and throat specialists are generally involved with the treatment of anterior neck lumps.  In this patients case, given the location of the mass, evaluation and treatment by a neurosurgeon is medically appropriate.  Due to the patients posterior neck pain and a mass at level of C2, a neurosurgical referral is standard of care.  All told, the requested consultation with a neurosurgeon 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 neurological 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: Overturned

Findings:  The physician reviewer found that An enrollees parent has requested authorization and coverage for occupational therapy (sensory integrative services). The records document that this patients primary diagnosis is autism. As is common with most patients with autism spectrum disorder, the patient has been impacted by multisensory processing abnormalities that began early in neurodevelopment and frequently interfere with the ability to perform activities of daily living. The patients provider states that the patient can benefit from sensory integration occupational therapy. As noted in the medical literature, no single pharmacotherapeutic approach can fully address the underlying causes for the deficits in patients with autism. Since sensory processing deficits are typically multifactorial in this patient population, tailoring a treatment regimen to the individual sensory processing deficits to improve function is critical. On review of the peer-reviewed clinical trials, sensory integration therapy is likely to be more beneficial for this patient than occupational therapy without the use of sensory integration (Kashefimehr, et al.; Randell, et al.). Given this support, the requested occupational therapy (sensory integrative services) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Two of the three physician reviewers found the requested occupational therapy (sensory integrative services) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: 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.
Appeal type: Urgent Care
Decision: Upheld

A 31-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that an emergency is the sudden onset of symptoms of such severity that a prudent layperson would believe his health to be in jeopardy without immediate medical attention. The patient was not experiencing fever or any other neurologic symptoms. His conditions had not changed suddenly according to the notes provided. The patient was described as without distress. Other than fluid in his middle ear, the patients examination was unremarkable. He was prescribed oral pain medications and discharged after obtaining a normal head CT scan. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize his health.
Appeal type: Medical Necessity
Decision: Upheld

A 31-year-old female enrollee has requested a panniculectomy/abdominoplasty procedure for treatment of her excess skin.  Findings:  The physician reviewer found that the patient has a body mass index of 26.5.  The color photographs reveal a female standing erect without obvious assistance and no abdominal pannus overhanging the inguinal ligament or mons pubis. She has excess skin of the mid abdominal wall. There is no skin ulceration noted. There is no evidence of subjective complaints of skin rashes in the clinical records or rashes documented by physical examination. There is a lack of documentation of a chronic skin problem with intertrigo, rashes and skin ulcerations with failure of conservative treatment over a period of time.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for tizanidine 2 mg capsules for the quantity of 60 capsules for 30 days. The submitted documentation fails to demonstrate the medical necessity of the requested medication regimen. Tizanidine is a central alpha-2 adrenoceptor agonist that has been approved by the United States Food and Drug Administration (FDA) for treatment of spasticity. Although there is a theoretical construct supporting the medication as an anxiolytic, namely the medications action of blocking neurons from releasing neurotransmitters which in turn reduces adrenergic activity, the medication is not approved for unspecified anxiety disorder and is not commonly used for anxiousness. Thus, the use of tizanidine in this case is considered off-label.  This patient has a formal thought disorder and is nonadherent with his antipsychotic medication which often decompresses secondary mood and anxiety symptoms for those with schizophrenia.  Further, there is no evidence or input from the provider that formulary equivalents would be inappropriate, unsafe or inadequate. Selective serotonin reuptake inhibitors and serotonin presynaptic agonists are first-line treatments for anxiety disorders, while medications such as hydroxyzine, gabapentin and low-dose quetiapine are often used on an as needed basis when benzodiazepine medications are contraindicated.  Therefore, for tizanidine 2 mg capsules for the quantity of 60 capsules for 30 days is not medically necessary for the treatment of this patient.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 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.