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

A 58-year-old female enrollee has requested an open MRI of the lumbar spine for evaluation of her lumbar spine condition.  Findings:  The physician reviewer found that according to the American College of Radiology Guidelines, the appropriateness of MRI is based on an individuals clinical history and physical examination findings. The indications for an MRI include the evaluation of such problems as degenerative disc disease, suspected spinal stenosis or bone metastases, and suspected infections; however, there is need for appropriate clinical evaluation prior to pursing this modality. (InterQual criteria) Studies have not shown improvement in treatment outcomes with MRI when not supported by objective tests and physical examination findings. (Rondsari and Jarvik) In the case of this patient, there is a lack of detailed documentation of the history of the patients problem. There is no documentation of the physical findings identified, other than tenderness. Further, there is no documentation of conservative treatment or the patients response to such measures. In the absence of such documentation, the medical necessity of an open MRI of the lumbar spine is not established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment. Findings:  The physician reviewer found that the documentation submitted does not support the medically necessity of the services at issue in this clinical setting. The patient was not in withdrawals. However, she was on methadone upon admission. Her use of Dilaudid was reported to be 2-3 times per week, not daily. She underwent an Ativan taper, with a methadone taper being planned for two weeks.  This pattern of use and detoxification plan did not require 24 hours per day at 7 days per week monitoring.  She was not a danger to herself or others.  She was not gravely disabled.  She was medically and psychiatrically stable.  There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care.   There was no evidence of a high degree of agitation, mania, hallucinations, or any other significant symptom that would interfere with her care.  She was motivated, cooperative, and appeared to be working the program.  Although she required further treatment to help deal with her emotions and develop coping skills, this did not require the structured environment of a residential setting.  She could have received treatment at partial hospitalization program level of care. Therefore, residential treatment provided during the dates of service in question was not medically necessary for the treatment of this patient. 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 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 reimbursement for residential treatment center (RTC) services from Hoag Neurobehavioral Health, LLC for treatment of her alcohol use disorder.Findings: The physician reviewer found that The residential treatment center (RTC) services provided by Hoag Neurobehavioral Health, LLC were not medically necessary for treatment of this patients behavioral health condition. There was no evidence of post-acute withdrawal symptoms, nor was there any evidence of danger to self or others. The patients alcohol related medical conditions could have been monitored on an outpatient basis and she was psychiatrically stable. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant the RTC level of care. She was motivated and appeared to be working the program. She demonstrated insight and motivation and she had a stable, sober support network. The issues she was working on in individual psychotherapy could have continued in an ambulatory based treatment. Relapse prevention could have continued at a lower level of care with the combination of a 12-step program, counseling, and maintaining contact with her sponsor. Thus, the services at issue were not medically necessary.Final Review: 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: Overturned

A 71-year-old male enrollee has requested Lovaza 4 g and Ranexa 500 mg for the treatment of his coronary artery disease and angina. Findings:  The physician reviewer found that Ranexa is being used in combination with a beta-blocker and a long-acting nitrate. Therefore, a trial of Ranexa is supported by the record and is medically reasonable and appropriate in this setting. Likewise, the patient has significant dyslipidemia and is intolerant to multiple cholesterol medications. Given the history of the patients intolerance to multiple other lipid reducing agents and the effectiveness of Lovaza in this patient, the continued use of Lovaza is reasonable and medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an eighteen year-old female with a history of depression and multiple suicide attempts is requesting authorization of continued treatment at a psychiatric residential level of care.Reviewers Findings:  The reviewing physician found that the submitted information is unclear on how residential treatment differed in any way from what could have been offered via partial hospitalization.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 63-year-old female enrollee has requested a total ankle replacement (Scandinavian Total Ankle Replacement - STAR)for treatment of her osteoarthritis of the ankle. Findings:  Two physician reviewers found that the patient has failed conservative management. She requires NSAIDs and Vicodin for pain management. The patients provider has recommended Scandinavian Total Ankle Replacement (STAR).  A well-accepted treatment for end stage ankle arthrosis is ankle arthrodesis. Arthrodesis fuses the ankle joint and places additional stresses on joints below the ankle joint. In many instances, this event may lead to arthrosis of the subtalar joint and midfoot. Total ankle replacements are an alternative to ankle arthrodesis. Saltzman and colleagues published a prospective, controlled trial of the STAR total ankle replacement. Treatment efficacy in patients with the STAR ankle was higher in the ankle replacement group when comparing the STAR ankle arthroplasty with ankle fusion.  After 24 months, ankles treated with the STAR ankle replacement had better function and equivalent pain relief as ankles treated with arthrodesis. The American Orthopedic Foot and Ankle Society and American College of Foot and Ankle Surgeons have issued position statements supporting total ankle replacement as an option for severe ankle arthritis. This patient has severe ankle arthritis, and her pain affects daily activities of living. There is no evidence of infection, no malalignment above or below the ankle, no evidence of neuromuscular disease and no circulatory issues. The current medical evidence supports the requested procedure in this clinical scenario. All told, the requested total ankle replacement (STAR) is likely to be the most efficacious treatment alternative.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old female enrollee has requested for a custom knee brace for treatment of the enrollees left knee post ACL reconstruction. Findings:  The physician reviewer found that there are insufficient reports in orthopedic sports medicine literature supporting the use of either prophylactic bracing or functional bracing of a stable, successfully reconstructed knee following ACL surgery.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for FoundationOne testing. Findings:  Three physician reviewers found that FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target which could guide the clinician as to which chemotherapeutic drug would be useful. However, there is a lack of convincing evidence that the assay adds to the decision making ability or yields a result that is reliably clinically beneficial. There are a variety of non-randomized studies exploring the value of molecular profiling, none of which have been convincing as to the efficacy of these analyses. A randomized study by Le Tourneau and colleagues did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the oncologists clinical judgment. Additionally, finding a mutation does not guarantee that a drug targeting that mutation will produce a clinically meaningful response. Therefore, FoundationOne testing was not likely to have been more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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 enrollee is requesting authorization and coverage for an electric scooter. The enrollee has worsening pain in both feet. A progress note includes diagnoses of corns and callouses, and pain to bilateral feet and ankles. The patient was evaluated by her treating physician.  Medical records show the patient had bilateral bunions, with thick tender callusing of both feet.  However, there were no focal deficits.  The upper and lower extremity motor and sensory examinations were described as normal and intact; respectively. The patient was assessed for an electric scooter by a physical therapist.  The therapist reported the patient is fully ambulatory, without the use of a device, such as a cane, and was not restricted from driving a motor vehicle.  The patient has the necessary upper extremity function to self-propel an optimally-configured manual wheelchair to perform activities of daily living or instrumental activities of daily living during a typical day. The physical therapist's evaluation also reported the patients wheelchair inaccessible apartment does not provide adequate access between rooms, in and out of the home, maneuvering space, over surfaces, nor a secure storage space for the operation of the power operated vehicle.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old female enrollee has requested speech therapy for treatment of the enrollees expressive and receptive language delays. Findings:  The physician reviewer found that the requested services of speech therapy for this patients speech and language delays are medically necessary based on an overall evaluation of the relevant medical literature. Lane and Schaaf discussed the notion of plasticity in the developing brain in terms of rehabilitation outcomes in young patients with developmental deficits. The authors noted that although the patients present with underlying neurologic disease, such as the pathogenetic process that gave rise to this patients cerebral palsy and speech and language delays, therapy can be utilized to improve overall neurologic health. Thus specific treatment, including speech therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic process. Taken together, speech therapy for this patient is necessary to reduce the physical and mental effects of her underlying neurologic condition and to achieve maximum function in maintaining daily activities.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested individual therapy with a psychologist every two weeks for medical treatment of her depression and anxiety. Findings:  The physician reviewer found that the records do not demonstrate that this patient has regularly followed up with the psychologists recommendations of anxiety skills group and DBT, which is the gold-standard treatment for patients struggling with interpersonal boundaries, character pathology and emotional dysregulation. All told, the medical records do not support the requested individual therapy with a psychologist every two weeks.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the inpatient psychiatric hospitalization level of care services. Findings:  The physician reviewer found that, based on the available records, the inpatient psychiatric hospitalization level of care services provided during the dates of service in question were medically necessary for treatment of this patients medical condition. The progress notes indicate that the patient was cooperative in treatment and open to therapy. The patient did express suicidal ideation on one of the dates of service in question, but not after that date. The progress notes did not indicate self-harm behaviors but rather vague suicidal ideation. Due to the fact that the patient was no longer suicidal and was cooperative in treatment it appears that a less restrictive setting was appropriate. The functional impairment that the patient was struggling with was likely due to borderline personality disorder. One of the mainstays of treatment for borderline personality disorder is dialectical behavior therapy, which can occur in a less restrictive setting once patients are free from safety concerns. Inpatient treatment is considered the highest level of psychiatric care available. Medical necessity guidelines indicate that psychiatric symptoms must be severe and present to the degree that this level of care is needed. According to the patients score on the Level of Care Utilization System (LOCUS), the patient was a candidate for treatment with high intensity community based services. For these reasons, the inpatient psychiatric hospitalization level of care services provided during the dates of service in question were medically necessary. Final Result: The reviewer determined that a portion of the services at issue were 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 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 49-year-old male who has been experiencing marital problems. The patient has been receiving psychotherapy since January 2003. The patient has also been in marriage counseling. The submitted notes indicate the patient has been diagnosed with adjustment disorder. A request has been made for continued psychotherapy sessions. The Health Plan has determined the requested therapy is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. Review of the submitted treatment notes reveals no medical justification for continued therapy. The patient has been diagnosed with an adjustment disorder, which is a condition typically considered appropriate for brief interventions. There is no indication of any serious symptoms in the submitted psychotherapy notes. The services recommended by the Health Plan appear to be medically reasonable and appropriate for treatment of the patients condition. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Zulresso. Zulresso is U.S. Food and Drug Administration (FDA) approved for the treatment of post-partum depression. The inclusion criteria used in the randomized controlled trial data that was submitted included patients ages 18-45 with moderate to severe depression and less than six months post-partum. As a rapidly acting medication, Zulresso is administered via intravenous infusion over 60 hours in a supervised inpatient setting. The FDA has approved Zulresso only for use in REMS qualified programs with the ability to monitor the patient over 60 hours for adverse effects. The data submitted to FDA indicates that it is effective in improving depressive symptomology and is safe to use in breastfeeding mothers. In this case, the patient gave birth on 8/14/20 via cesarean section and she is less than six months post-partum. Per the medical documentation, the patient has a diagnosis of moderate major depressive disorder and she is younger than 45-years-old. The patient was evaluated and found to have a personal health questionnaire 9 (PHQ-9) score and symptom history consistent with moderate to severe depression. The patient has been treated with psychotherapy and a selective serotonin reuptake inhibitor with persistence of symptoms. The medical documentation suggests that the patient continues to have functional disabilities to care for herself and her child, placing their wellbeing at risk. Despite six weeks of intensive psychiatric treatment, the patients PHQ-9 supports moderate to severe depression. The patient has experienced some improvement with the structure of IOP and PHP. For these reasons, the medication Zulresso services is medically necessary for 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 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

A 49-year-old female enrollee requested authorization and coverage for a homocysteine blood test. The health plan has denied this request indicating that the requested test is not medically necessary for treatment of the enrollee.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested testing is not medically necessary, as there is no evidence the patient has cardiovascular or peripheral vascular disease.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for treatment of his hepatitis C.  Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions.  In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 12 weeks.  For these reasons, the requested treatment with Sovaldi and Daklinza is medically necessary for the treatment of this patients hepatitis C infection. 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 internal medicine with sub-specialty certification in gastroenterology 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 63-year-old male enrollee has requested a three piece inflatable penile prosthesis for treatment of his erectile dysfunction. Findings:  The physician reviewer found that treatment of erectile dysfunction is goal directed; appropriate therapy is based on what is successful and acceptable to the individual patient. Although erectile dysfunction is often viewed as only a physical dilemma, the individuals psychological insult and emotional well-being are also affected, as his body is failing in a simple physical function. To regain medical wholeness requires that the patient be given control of his condition in such a way that would allow for the level of activity to which the individual wishes to return. Additionally, the three piece implant is the only device reviewed in the peer reviewed medical literature which approaches that result. Therefore, the requested equipment is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 19-year-old male enrollee requested authorization and coverage of the medication actos for the treatment of diabetes.  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 overturned the health plans denial on the basis that the requested medication is medically necessary for treatment of the patients medical condition.