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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment center (RTC) services for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that the patient was showing mild post-acute withdrawal symptoms, described as anxiety and cravings. He was not a danger to himself or others. He was medically and psychiatrically stable. He was motivated and was described to be working the program. He demonstrated insight in that he knew his triggers and barriers to recovery. His family and girlfriend were supportive, albeit described as enablers. His living environment was conducive to recovery. No new problems had arisen and no medication changes were made that required RTC level of care. The issues the patient was focusing on in individual psychotherapy could have continued on in an ambulatory setting. The patient no longer required 24-hour supervision, and could have been stepped down to PHP level of care. Thus, the RTC services provided were not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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

The parent of a 13-year-old female enrollee has requested a continuous glucose monitoring system (CGMS) for the treatment of the enrollees type 1 diabetes. Findings:  Three physician reviewers found that the patients family and treating physician have been diligent in their efforts to improve diabetes control and to prevent hypoglycemic episodes, especially during the night. The device appears clinically appropriate and indicated in this setting. The large numbers of data points (5 minute intervals throughout the day and night) will help the physician and family to gain new insights that will allow for insulin adjustments to minimize the current large glucose fluctuations. Such insights often cannot be deduced from the usual 3-5 point blood glucose levels in a 24-hour period that are traditionally taken. The alarm system on the device will also let the family know when hypoglycemia occurs so that adjustments can be made in a timely manner to minimize glucose rebound.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for morphine. Researchers found adequate evidence to support short-term efficacy of opioids for chronic low back pain compared to placebo. Researchers determined that for patients with chronic low back pain who tolerate the medicine, opioid analgesics provide modest short-term pain relief but the effect is not likely to be clinically important within guideline recommended doses. Overall, researchers found that there is a paucity of evidence supporting the long-term efficacy of opioid medications for patients with chronic low back pain. Further, researchers reported on an outcome study on the effects of opioid therapy for lumbar disc herniation. Researchers found that patients who were treated with opioids had significantly worse baseline pain and quality of life. At final follow-up, there was no long-term difference in outcome associated with opioid pain medication use. In this case, the patient has been on high dose opioid therapy with morphine and Norco. She has chronic low back pain with radicular pain and lumbar spondylosis. She has been resistant to treatment with non-opioid strategies for managing her pain, including pain management injections. Her providers have recommended a slow tapering of morphine while continuing Norco for pain. A review of the records reveal the most recent bone density scan was significant for osteoporosis and the patient has a history of falls. High-dose opioid therapy has been shown to worsen osteoporosis in patients on long-term therapy. Based on the available records for review and the lack of evidence supporting long-term high-dose opioid therapy for non-cancer pain, the request for morphine is not medically necessary for 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 Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for injections of dehydrated alcohol solution in the left foot. Sclerosing injections have not been demonstrated to be more beneficial for treatment of neuromas than presently available standard therapies. Studies show inconsistent results that do not demonstrate an improvement in outcomes over traditional therapies. One study evaluated injection with alcohol sclerosant for Mortons neuroma. The study concluded that although short-term results are encouraging, alcohol injection does not offer permanent resolution of symptoms for most patients and can be associated with considerable morbidity. Therefore, the requested injections of dehydrated alcohol solution in the left foot are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the requested injections of dehydrated alcohol solution in the left foot are 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. Final Result: The reviewers determined that the requested injections of dehydrated alcohol solution in the left foot are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Credentials/Qualifications: Medical professional reviewers 1 and 2 are board certified in podiatry and are actively practicing. Medical professional reviewer 3 is board certified in orthopedic surgery and is 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: Urgent Care
Decision: Overturned

A 28-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that this case involves the issue of whether a reasonable and prudent layperson in the patients circumstances would belief he was experiencing an emergency medical condition. An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. Review of the submitted clinical evidence demonstrates that the patients symptoms were acutely new. In addition, the pain involved the chest and left arm. The provider performed testing to exclude both an acute myocardial infarction and a pneumothorax, both of which are life-threatening medical problems. It is reasonable that a layperson with acute onset of chest and left arm pain would be concerned that a serious medical problem might have developed which required immediate medical attention.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1b patients should be treated with regimens including Zepatier for 12 weeks, based on clinical trial results showing a 99% cure rate regardless of NS5A resistance. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication regimen 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 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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Euflexxa injections. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients medical condition. The submitted documentation supports the medical necessity of the requested medication. The current literature supports the use of viscosupplementation for osteoarthritis of the knees. There is evidence that intra-articular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long lasting as compared with intra-articular corticosteroids. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. The researchers noted that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Therefore, the requested Euflexxa injections 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 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: Upheld

A 55-year-old female enrollee has requested care with a retinal specialist for the treatment of her retinal dystrophy. Findings:  The physician reviewer found that this patient has a long-standing, stable retinal condition that requires routine follow up care by an ophthalmologist who is skilled in evaluating retinal pathology. However, there is no evidence in the scientific literature that shows that a skilled ophthalmologist must be a retinal specialist. The decision to refer a patient to a retinal specialist is typically made by a comprehensive/general ophthalmologist, or optometrist, which probably occurred with this patient prior to the first time she saw the retinal specialist. However, with three consecutive stable exams over a three year period and with no treatment by that specialist, it is reasonable for this patient to be referred back to a comprehensive/general ophthalmologist within the Health Plan to evaluate not only the retinal dystrophy, but to evaluate the risk of other visual pathology (refractive error, glaucoma, cataracts, etc.). If the general ophthalmologist detects a change in the patients retinal dystrophy on routine yearly examination or the patient has a change in her vision, then a referral to a retinal specialist for further evaluation and management would be medically necessary. However, yearly examinations by retinal specialists are not medically necessary for patients with stable retinal dystrophies that require no treatment.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for outpatient intravenous immunoglobulin (IVIG) infusions (2 gram/kg administered twice a day, given every four weeks). The utilization of IVIG in this patient is consistent with the recommendations in the current medical literature (Kinsella, et al.). There are multiple case reports and reviews that have demonstrated evidence of clinical improvement in patients with autoimmune encephalitis treated with IVIG. Abboud and colleagues noted that IVIG is a relatively easy-to-use and timely option for fast immunomodulation when corticosteroids are contraindicated or when the clinical picture is suggestive of or known to be related to antibody-mediated disease. The records provided for review document that this patient has failed conservative therapies for treatment of relapsing and remitting mood changes with a diagnosis of autoimmune encephalitis. The patients autoimmune encephalitis has already responded well to treatment with IVIG, and the patient is a candidate for additional treatment. All told, the requested outpatient IVIG infusions (2 gram/kg administered twice a day, given every four weeks) are 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 60 days of intensive outpatient program (IOP) services for treatment of the enrollees autism spectrum disorder and anxiety. Findings:  The physician reviewer found that the request for 60 days of IOP services is medically necessary for treatment of the patients medical condition. There is sufficient peer-reviewed literature supporting the medical necessity of early intervention services for children diagnosed with an autism spectrum disorder. Estes and colleagues examined children enrolled in a multidisciplinary team approach such as the proposed IOP program in this case. The authors noted that significant gains were demonstrated in overall functioning that was sustained on follow evaluations two years later. Occupational therapy has also shown to be beneficial in the treatment of autism, addressing postural control and adaptive skills for long term independence. In addition, the use of cognitive behavioral therapy has been shown to be beneficial in the care of children with autism, successfully addressing common problems such as feeding difficulties. Given the support in the medical literature demonstrating benefit of early intervention for children with autism, coupled with the aforementioned efficacy of speech, occupational and cognitive therapies the request for IOP is medical necessity for treatment of the patients medical condition. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 female enrollee requested authorization and coverage for continued treatment with an out-of-network allergist. The health plan has denied this request indicating that it is not medically necessary for the enrollee to continue services with an out-of-network allergist of the enrollee's allergic symptoms caused by mold exposure.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 are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 36-year-old female who has a history of morbid obesity. She underwent gastric bypass in April 2002. She has reportedly lost 100 pounds since the procedure. In addition, the patient underwent an abdominoplasty in April 2003. The patient reports she has an excess amount of fat in her mid to lower back, which causes her pain and interferes with her ability to sit and sleep. She has requested a consultation with a plastic surgeon for possible removal of the excess skin.Review of the submitted materials does not demonstrate the requested consultation is medically indicated. The patient is seeking liposuction or another surgical procedure to remedy pain and discomfort that she attributes to excessive fat accumulated in her back. It is unlikely the fat itself is the cause of this discomfort, and highly unlikely that liposuction alone will remedy the problems the patient is experiencing. There is no evidence in the relevant medical literature that localized non-inflamed fat accumulations are a cause of pain. Furthermore, there is no evidence that liposuction is a modality for treatment of pain from any cause. Therefore, I have determined that the requested consultation is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee requested requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation (TMS) for treatment of the enrollees behavioral health condition. Findings: Three physician reviewers found that there is ample support in the medical literature and in the documentation provided for the efficacy of TMS in this patients case. The patients history outlines treatment resistant major depressive disorder. Whether or not there were underlying bipolar II issues, this patient has a longstanding major depressive illness which has been essentially unresponsive to multiple medication trials (greater than the four), or has suffered from side effects, and was fearful of ECT/anesthesia. However, the records reflect that she has shown a robust response to the TMS treatments she received, and has been medically stable.  For these reasons, TMS past treatments and forward were and are likely to have been more effective than the standard options available for treatment of this patients medical condition. Final Result: The reviewers determined that the services at issue were and 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. Credentials/Qualifications: All three physician reviewers are board certified in psychiatry and are actively practicing. The reviewer 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 acupuncture for treatment of her lower back pain. The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. Acupuncture is recommended as an option for chronic low back pain using a short course of treatment in conjunction with other interventions. Acupuncture has also been found to be more effective than no treatment for short-term pain relief in chronic low back pain ). According to the documentation submitted for review, the patient has not been treated with an acupuncture trial for her chronic lower back pain. Given the patients continued severe symptoms despite previous treatments including multiple surgeries, multiple injections, oral medication and self-care the requested services are supported by the peer review literature as medically necessary. Based on the reasons provided, acupuncture is medically necessary for treatment of the patients chronic low back pain. 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 oriental 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral functional custom foot orthotics. The requested bilateral functional custom foot orthotics are medically necessary to treat this patients plantar fasciitis. The current standard of care utilizes custom functional supportive orthotics to treat plantar fasciitis, arch pain, and heel pain. In this case, the patient has plantar central arch and heal pain bilaterally. Physical therapy reported a diagnosis of plantar fasciitis. The patient previously underwent surgical correction of plantar fasciitis on the right side. The progress notes from patients provider recommended custom functional orthotics to treat the patients arch and heel pain and plantar fasciitis. Based on current medical guidelines, the requested bilateral functional custom foot orthotics are medically necessary.Final Result: The reviewer determined that the requested equipment 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 podiatry 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.