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

A 64-year-old female enrollee has requested inpatient psychiatric services and hospital stay for treatment of the enrollees anxiety and depression.  Findings:  The physician reviewer found that The American Psychiatric Association (APA) practice guideline states that hospitalization should be considered for patients who pose a serious threat of harm to themselves or others. This patients records demonstrate that she was severely depressed with ongoing suicidal ideation throughout her admission. The treating providers were not confident that the patient would not intentionally overdose once discharged and thus gave her family the medications, which is an indication that patient was at risk of suicide until the last day of admission. Her risk factors for suicide included depressive disorder, anxiety disorder, chronic pain and social isolation. All told, acute inpatient hospitalization from the time frame specified was medically necessary to treat this patients condition, was consistent with standards of good medical practice, and could not have been provided safely in a less restrictive treatment setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for hormone pellets on for the treatment of the enrollee who has a history of low testosterone and low estrogen levels. Findings:  Three physician reviewers found that compounded drugs are not regulated by the U.S. Food and Drug Administration (FDA). They have the same risks as FDA approved hormone therapies, and they also may have additional risks because of the way they are made. There is a lack of scientific evidence that compounded hormones are safer or more effective than standard hormone therapy. Because of a lack of FDA oversight, most compounded preparations have not undergone any rigorous clinical testing for either safety or efficacy, and the purity, potency, and quality of compounded preparations are a concern. Some of these more traditional therapies may include, exercise weight loss, topical lubricants and moisturizers, topical estrogens, stress reduction, biofeedback, counseling, and serotonin reuptake drugs. In this patients case the chart indicates a list of the patients menopause complaints, but there is no mention of management options. The records provided do not indicate whether the patient has tried any other medicinal and nonmedicinal form of therapy. Despite the success this patient may be experiencing with her menopausal symptoms with her current therapy, the medical evidence does not support its superiority as first line therapy. Final Result: Three reviewers determined that the medication at issue was not and 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: All three physician reviewers are board certified in obstetrics and gynecology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement for residential treatment center (RTC) services. Applying LOCUS, the patient met the criteria for RTC services. The patient presented with some risk of harm, given the lack of suicidal ideation or safety concerns. However, the records document issues of self-neglect as a result of his obsessive compulsive disorder (OCD) behaviors. The patient demonstrated severely impaired functional impairment. The patient has not been able to participate in school or work and has no social relationships. The records document a history of comorbid ADHD. The patients recovery environment was mildly stressful. He had no supports outside of his father. The patients recovery environment was supportive. He had an outpatient therapist. The provider noted that there were no community-based services for OCD available. The patient demonstrated limited improvement with treatment due to his severely refractory OCD. He has failed outpatient treatment as well as several medications trials and RTC admissions. However, based on his score for functional status, he met the criteria for medically monitored residential services. Moreover, RTC has been found to have improved outcomes for patients with severely refractory OCD. All told, the RTC services received were medically necessary for treatment of this patient.Final Result: The 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 reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 42-year-old female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is considered experimental for the treatment of the enrollees migraine headaches.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two CHDR physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of your medical condition than any available standard therapy. One CHDR physician reviewer concluded that the requested therapy is not likely to be more beneficial for treatment of your medical condition than any available standard therapy. Because two of the three CHDR physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of your medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee has requested a nerve block (lumbar diagnostic medial branch block) for treatment of her low back pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The medical literature shows evidence for diagnostic lumbar facet injections in treating facet syndrome when the patients are appropriately selected.  However, the current medical evidence does not support the requested services in this clinical setting.  The patient had a positive straight leg raise test on physical examination and no recent magnetic resonance imaging or electrodiagnostic testing to rule out radiculopathy.  Her pain is possibly typical of lumbar radiculopathy versus lumbar facet syndrome or both.  Per the submitted records, it is difficult to determine the pathology of the patients pain and therefore appropriately treat her pain.  All told, the requested nerve block (lumbar diagnostic medial branch block) is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement for residential treatment center (RTC) and prospective authorization and coverage for RTC services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for RTC level of care services provided, and for an additional 28 days of RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Given the findings, the RTC services provided and 28 days of RTC level of care services, are consistent with the ASAM requirements for medically necessary mental health services. 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 psychiatry with expertise 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast cancer screening.  Findings: Three physician reviewers found that Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has breasts that have been described as heterogeneously dense. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  In addition, the calcifications can be better characterized with tomosynthesis. Accordingly, the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continuous passive motion (CPM) machine (E0935). Hill and colleagues found that the results of their study suggest that the use of CPM in the immediate postoperative period following the treatment of intra-articular fractures offers no benefit with regard to knee motion at six months and is not tolerated by all patients. Schulz and colleagues concluded that controlled active motion (CAM) therapies and CPM lead to significant improvements after total knee arthroplasty, but CAM showed better results in term of flexion, pain and quality of life. Harvey and colleagues reported that CPM does not have clinically important effects on active knee flexion range of motion, pain, function or quality of life to support its routine use. This patient is status post left total knee replacement. The patient was treated in a skilled rehabilitation facility for one week following the surgery. While in the rehabilitation facility, she utilized a CPM machine. The provider recommended use of a CPM machine to be used at home. However, there is a paucity of large-scale, peer-reviewed medical literature demonstrating that use of a CPM device in this patients clinical setting is effective in improving patient health outcomes. In addition, there is a lack of documentation in the patients records that CPM use is required in lieu of physical therapy to address any significant postoperative deficits in range of motion. Moreover, detailed documentation is not evident regarding any significant improvements in the patients range of motion with the use of the CPM machine while in the rehabilitation facility. All told, the requested CPM machine (E0935) is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested device 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Genotropin.Findings: Two of the three physician reviewers found that the requested medication is not indicated under these circumstances. The patient, labeled as idiopathic short stature (ISS), most likely has had a normal variant of constitutional delay of growth and development based on his clinical course and his normal growth velocity prior to receiving recombinant human growth hormone (rhGH) treatment. The FDA has approved only rhGH to treat ISS, and the various FDA-approved formulations of rhGH are bioequivalent. While receiving rhGH for ISS, this patient entered puberty. Now beyond the midpoint of puberty, he recently displayed a height percentile above his mid-parental target height (MPTH) percentile. It appears doubtful that this patient still requires exogenous rhGH to attain a height within 1.5 standard deviations of his MPTH. No FDA-approved formulation of rhGH for daily administration, such as the requested medication, Genotropin, is likely to be more beneficial than another FDA-approved formulation for daily treatment of this patient with a history of short stature. Specifically, the requested medication (Genotropin) is not likely to be more beneficial for treatment of the enrollees medical condition (neither ISS nor constitutional delay) than any available standard therapy of daily rhGH.Final Result: The reviewers determined that the requested medication 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: All three reviewers are board certified in pediatrics, with subspecialty certification in pediatric endocrinology, and all three are actively practicing. All three 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla starter pack and Otezla 30 mg tablets.Otezla (apremilast) has been approved by the U.S. Food and Drug Administration and is indicated for the treatment of moderate-to-severe psoriasis and psoriatic arthritis. Medical literature stated, There is good evidence that many of the biologic treatments initially tested in psoriasis are also effective in psoriatic arthritis. Many published articles confirm that the use of Otezla with biologic medications is safe. In a trial by researchers, apremilast was proven to be safe. The authors noted, No significant adverse events emerged with continued apremilast exposure versus the placebo-controlled period. In this case, the patient has three distinct autoimmune inflammatory diseases that require therapy. The patients Crohns disease is now well-controlled on Humira, a biologic medication. However, her psoriasis and psoriatic arthritis are poorly controlled on Humira. As a result, her rheumatologist recommends Otezla to better control the psoriasis and psoriatic arthritis. There is sufficient support for the requested medication in this clinical setting. Therefore, the requested Otezla starter pack and Otezla 30 mg tablets are medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medications 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 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 parent of an enrollee has requested inpatient psychiatric hospitalization for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  This patient was severely ill when she was admitted to the hospital with a psychotic mania.  She had already been treated at an acute level followed by residential level of care, without improvement.  This was a complicated clinical presentation, as the patient did not respond to medication and treatment in the usual way.  Although her symptoms were subsequently well controlled, she was experiencing important side effects of hypersalivation, muscle rigidity and muscle stiffness.  The provider determined that the patient needed a reduction in the dosage of her medications to address these issues.  However, given her treatment history, reducing her medication came with a significant risk of relapse.  Therefore, it was prudent and medically necessary to begin this medication reduction while she was still in hospital and could be closely observed.  Eventually, she tolerated the changes and was showing a decrease in side effects.  Therefore, plans could have been made to safely discharge her home.  All told, inpatient psychiatric hospitalization was initially medically necessary, but not thereafter. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Ajovy 1.5 mL injection once a month. Calcitonin gene-related peptide (CGRP) monoclonal antibodies are biologic agents that have been demonstrated to be effective, safe and well tolerated for the preventive treatment of episodic and chronic migraine in phase 2 and phase 3 randomized, placebocontrolled trials. Urits and colleagues noted that randomized placebo-controlled trials in adults with episodic and chronic migraine validated the effectiveness of fremanezumab as preventive therapy for migraine. In this case, the patient has a history of chronic migraines that did not respond to multiple oral preventative medications. However, the patients migraines improved in severity when treated with Ajovy. Based on the available documentation, this patient meets the American Headache Society (AHS) criteria for initiation of CGRP monoclonal antibody therapy. For these reasons, the requested Ajovy 1.5 mL injection once a month is medically necessary for the treatment of the 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 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

A 37-year-old female enrollee has requested breast reduction surgery without a six-month nicotine-free interval for treatment of her macromastia without a six-month nicotine-free interval.   Findings:  The physician reviewer found that recent studies support the premise that smoking (nicotine) increases the risk of surgical complications following breast reduction surgery. According to Chan and others nicotine is associated with a significant increase in wound healing problems. Moreover, the study by Bikhchandani, et al, reached the following conclusion: Stoppage of smoking in the peri-operative period should be adopted as an essential eligibility criterion for breast reduction. According to the literature, the likelihood of an uncompromised outcome is increased if the patient is nicotine-free for one month prior to breast reduction surgery.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for fentanyl lollipopsFindings:  The physician reviewer found that the physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has violated opiate maintenance agreements in the past.  The use of fentanyl immediate-release would be off-label since its use is limited to cancer-related breakthrough pain. There is considerable risk in providing high-dose opiates for chronic non-malignant pain. The Centers for Disease Control and Prevention guidelines state established patients already prescribed high dosages of opioidsshould be offered the opportunity to reevaluate their continued use of opioids at high dosages in light of recent evidence regarding the association of opioid dosage and overdose risk. The medical evidence does not support the requested medication in this clinical setting. All told, the requested fentanyl lollipops are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the 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. Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee requested speech therapy for medical treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of speech therapy in this patients case.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  This patient has demonstrated varying degrees of expressive language delay, including difficulty with pragmatic speech.  The literature supports the use of speech and language therapy for expressive language delay.  All told, the requested speech therapy is medically indicated for the treatment of this patient.