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

Nature of Statutory Criteria/ Case Summary:  The parent of an enrollee has requested reimbursement for residential treatment center (RTC) services. The enrollee has a history of attention deficit hyperactivity disorder (ADHD). Her parents enrolled her in residential treatment level of care after she had been displaying increasingly defiant and self-destructive behavior. According to the medical literature, children and adolescents with mental illness should be treated in the least restrictive environment, unless community-based settings are not appropriate as a result of the severity of an individuals psychiatric illness and then, in those instances, residential treatment may be considered. This enrollee, at the time of admission, was exhibiting some oppositional and socialization problems. However, the most critical symptoms were those of mood instability and difficulties with emotional self-regulation.  The purpose of residential services is typically to provide 24-hour care and monitoring inclusive of daily individual and group interventions. Based on the enrollees presentation at the time of admission, she could have been safely treated at a lower level of care. Her symptoms of low-grade anxiety and depression combined with behavioral opposition and substance abuse did not warrant the residential (RTC) level of care. Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Therefore, the health plans denial should be upheld. Credentials/Qualifications: The clinical reviewer is board certified in Psychology 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 50-year-old male who suffered a clavicle fracture in July 2004 as a result of a motorcycle accident. He is requesting authorization for a bone growth stimulator to expedite the healing process. The Health Plan has denied this request.The vast majority of clavicle fractures (99%) heal within six weeks by non-surgical means. A bone growth stimulator is not indicated unless a delayed union or non-union develops. These generally are found two to three months following the injury. This patient had no evidence of delayed union or non-union when the stimulator was requested and it appears the equipment was requested to attempt to expedite the healing process. There is no evidence the patient required or requires a bone growth stimulator for medical reasons. Therefore, I have determined the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee requested authorization and coverage of gastric bypass surgery for the treatment of morbid obesity.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested surgery is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Ajovy 225 mg/1.5 mL prefilled syringe. The U.S. Food and Drug Administration (FDA) approves the use of Ajovy, a calcitonin gene-related peptide (CGRP) antagonist, for the preventive treatment of migraines in adults. The American Headache Society (AHS) notes that treatment with monoclonal antibodies to CGRP may be indicated for patients with chronic migraines with an inability to tolerate topiramate and serotoninnorepinephrine reuptake inhibitor such as venlafaxine and duloxetine. The AHS recommends that clinicians and patients reassess the benefits of CGRP monoclonal antibody therapy after three to six months and continue treatment if benefits, such as a reduction in mean monthly headache days, can be documented. In this case, the patient has a history of chronic migraines that have not responded to multiple preventative medications including Topamax, venlafaxine, and duloxetine. The use of Ajovy has been effective in decreasing the frequency of the patients migraines from up to nine days per month to one day per month. Given that the patient fits AHS criteria for treatment with CGRP monoclonal antibody therapy, the requested medication is medically indicated. Therefore, Ajovy 225 mg/1.5 mL prefilled syringe 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 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: Overturned

A 49-year-old female enrollee has requested for transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder.  Findings:  Three physician reviewers found that TMS is an effective treatment supported by the evidence-based literature. Further, TMS is widely practiced throughout the U.S., has been granted a category I CPT code by the American Medical Association (AMA), and is FDA approved for patients with treatment-resistant MDD. Consistent with this support, TMS therapy is a reasonable treatment choice that was and is likely be more beneficial for treatment of the patients medical condition than any available modality for her depression.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency neurolysis for treatment of her sacroiliitis. Findings:  Two physician reviewers found that overall, there is lack of evidence to permit conclusions on net health outcomes in well-designed randomized controlled trials with adequate follow-up regarding radiofrequency ablation for SI joint pain. Researchers demonstrated no high-quality evidence suggesting that radiofrequency denervation provides pain relief for patients with chronic low back pain. Other researchers performed a systematic review with analysis. The authors stated that evidence of moderate quality exists on therapeutic procedures, but it is insufficient to determine the indications and effectiveness of sacral lateral branch thermal radiofrequency neurotomy, and more research is required. All told, there is paucity of data to support the requested radiofrequency neurolysis as 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 procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in orthopedic surgery and 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

The patient is an 11-year 4-month old male with short stature. He was a full-term baby who was small for gestational age (SGA) weighing only five pounds. He has not shown catch-up growth. He attends a special educational school. In October 2004, the patient was evaluated by an endocrinologist who noted the patient was 113.5 cm tall (4.5 SDs below the mean) and weighed 19.6 kg (below the 3rd percentile). The patients IGF-1 was 133 and IGFBP-3 levels were normal. He had good growth hormone responses to argine and clonidine at peaks of 15ng/ml, thereby ruling out growth hormone deficiency. His parents height is listed at 150 cm (mother) and 168 cm (father). The patients bone age was 9 years at age 10 years and 5 months. His growth velocity was 3 cm per year. He was started on growth hormone therapy in April 2005. His thyroid tests were normal. A SHOX gene test was contemplated but it is unknown if the test was performed. The patients adult height prediction falls short of 5'.At issue is whether growth hormone therapy is medically necessary for treatment of the patients medical condition.Based on the submitted clinical information, the patient does not have growth hormone deficiency. However, the patient has been diagnosed as SGA and has not exhibited catch-up growth. Additionally, the patient has a family history of short stature. The patient apparently does not have features of Russell-Silver Syndrome. SGA is an approved indication for growth hormone therapy. A trial of growth hormone therapy is medically reasonable and appropriate in this clinical setting and should be authorized. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old male enrollee has requested additional Synvisc One injections for the treatment of his knee pain. Findings:  The physician reviewer found that viscosupplementation has been found to be an effective treatment for osteoarthritis of the knee, as noted by Bellamy and colleagues. It is well-tolerated, and the incidence of adverse events is low, per Brzusek and Petron. Repeat courses of therapy have been well-tolerated, although a slight incidence of adverse events has been noted. The criteria for a repeat course of viscosupplementation include a favorable response to the initial series and several months before the return of symptoms. In this patients case, these criteria are met and documented in the record. Since adverse events are not documented, there is no contraindication to a repeat series of injections. Synvisc One injections are medically indicated for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a five-year-old male enrollee have requested speech therapy for the treatment of the enrollees pervasive developmental disorder. Findings:  The physician reviewer found that this child has been in continuous speech therapy since the age of two. The weekly individual program is now integrated in a public school program. The child has shown significant improvement in the program. This combined program is medically necessary to bring the child up to normal language skills. Most recent tests have placed him in the 16th percentile of receptive language, which qualifies him for continued speech therapy. Speech therapy is indicated and appropriate for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for diagnostic facet injections of C2-3, C4-5 right side, and C6-7 bilateral. In a systematic review, Chou and colleagues report that despite an overall paucity of high quality studies and more specifically the lack of investigations related to thoracic facet joint injection, there is evidence supporting the use of therapeutic facet joint nerve blocks in the cervical, thoracic, and lumbar spine. Cohen and colleagues conclude, Facet injections appear to have little long-term utility, though they may provide prognostic value compared to control injections before radiofrequency ablation. Multicenter randomized trials are needed to ascertain the best way to diagnose facet joint pain, confirm the efficacy of radiofrequency ablation, and determine which patients benefit most. Manchikanti conclude, Based on the present assessment for the management of spinal facet joint pain, the evidence for long-term improvement is Level II for lumbar and cervical radiofrequency neurotomy, and therapeutic facet joint nerve blocks in the cervical, thoracic, and lumbar spine. In this case, the patient reports neck pain that radiates down the right side of his neck and into his right shoulder that is aching and sharp. An examination showed tenderness in the midline of the cervical spine and noted the following for the patients cervical range of motion: flexion 20 degrees, extension 20 degrees, left and right lateral flexion five degrees, and left and right lateral rotations 75 degrees. The patient had full strength and intact sensation in the bilateral upper and lower extremities. Deep tendon reflexes were noted as 0/4 in the bilateral upper and lower extremities. In this case, the records do not include detailed documentation regarding facet-mediated pain. The records include plausible evidence of radiculopathy and note that the patient has undergone previous facet joint injections. In this clinical setting, current medical literature does not support the efficacy of medial branch nerve blocks. In this case, given that there is limited published, large-scale, long-term peer-reviewed literature demonstrating the safety and efficacy of repeat facet injections, the requested services are not medically indicated. Therefore, diagnostic facet injections of C2-3, C4-5 right side, and C6-7 bilateral are 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vyzulta eye drops for treatment of the enrollees open angle glaucoma.  Findings:  The physician reviewer found that The submitted documentation supports the medical necessity of the requested medication. Vyzulta (latanoprostene) is a new medication that combines latanoprost with nitric oxide. This medication has been shown to lower intraocular pressure better than latanoprost. In this patients case, given that the pressure in the right eye has not been adequately controlled, Vyzulta is medically appropriate. There is sufficient support for the requested medication in this clinical setting. Therefore, Vyzulta eye drops are 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 ophthalmology 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 Latuda prescription for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that Lurasidone is an atypical, or second generation, antipsychotic medication initially approved for the treatment of schizophrenia. In mid-2013, lurasidone gained two additional indications, both for the treatment of bipolar illness, and is one of only three U.S. Food and Drug Administration (FDA) approved medications for bipolar depression.  The other two, quetiapine and olanzapine-fluoxetine combinations, are frequently associated with weight gain, glucose intolerance and dyslipidemia.  The medical evidence appears to indicate that lurasidone is associated with fewer metabolic side effects and less weight gain. The Health Plan suggested aripiprazole as an alternative.  However, the data supporting aripiprazole as a monotherapy or in conjunction with lamotrigine in the treatment of bipolar depression are weak when compared to lurasidone. Lurasidone is approved by FDA for this patients condition and is reasonably expected to improve the patients condition and to prevent a more serious episode of illness.  Therefore, Latuda is medically necessary for the treatment of this patients medical condition. 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 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: Upheld

The patient is a 14-year-old female with a recent history of risky behavior. She has been exhibiting acting out behaviors since the age of 10. She has a history of running away from home and drug and alcohol abuse. Recently, the patient was placed on a 5150 psychiatric hold after she assaulted a family friend who attempted to prevent her from running away. On 7/16/04, the patient was admitted to a residential psychiatric treatment facility. The submitted treatment notes indicate the patient is not suicidal. On 8/10/04, the patients psychiatrist noted there was no need for psychotropic medication. A request has been made for continued residential psychiatric treatment services. The Health Plan indicates the submitted documentation does not demonstrate continued residential psychiatric treatment is medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. The submitted records do not demonstrate that the patient is suicidal or a danger to others. It appears the patient participated appropriately during residential treatment and evidenced no self-destructive behavior or high-risk taking behavior. Furthermore, the patients provider indicates the patient does not require psychotropic medication. The patient is cooperative with therapy and her family is supportive. Thus, the submitted evidence does not demonstrate the patient continues to require residential psychiatric treatment services. Transition to a lower level of care is medically reasonable and appropriate.Based upon the information set forth above, I have determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old male enrollee has requested magnetic resonance imaging-guided chemolytic ablation treatments performed on the right middle scalene, levator scapula and trapezius for treatment of his right upper extremity neurologic symptoms. Findings:  Two physician reviewers found that the procedure performed was not likely to be more beneficial than standard therapies for treatment of the patients medical condition. There was not a firm basis for diagnosis of thoracic outlet syndrome (TOS) and the procedure has not been shown to be more efficacious than other standard therapies. The diagnosis of TOS is often made by using electrodiagnostic and vascular studies, yet the diagnosis is questionable based on imaging reports. Specifically, the irritative effects as noted on the imaging report could be related to recent procedures done in that area or could be of no clinical significance at all. Nevertheless, even if the patient did have a diagnosis of TOS, the treatment provided is not standard and was not likely to be more beneficial than standard therapies for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Cosentyx for treatment of his medical condition.  Findings:  The physician reviewer found that the patient is requesting coverage for Cosentyx as treatment for his long-term plaque psoriasis.  He has had a trial of this medication which resulted in 100% clearance of his skin.  Over several years, the patient has already tried and failed therapy with topical steroids, ultraviolet B (UVB) phototherapy, and several medications.  It is not medically reasonable to require the patient to try and fail therapy with a biologic medication in the same class as another medication he failed prior to authorizing treatment with Cosentyx. Additionally, it is not medically reasonable that the patient be expected to repeat another trial of each of these medications prior to authorizing treatment with Cosentyx.  There is sufficient support for the requested medication in this clinical setting.  All told, Cosentyx is medically indicated 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.