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

An enrollee has requested authorization and coverage for ketamine infusions. The records indicate the patient has a history of depression as well as anxiety and obsessive-compulsive disorder symptoms. The recent progress notes indicate that the patients treating providers have recommended electroconvulsive therapy for his medication-resistant depression. The current evidence regarding ketamine is limited in nature. Colleagues noted the antidepressant efficacy of ketamine, and perhaps D-cycloserine and rapastinel, holds promise for future glutamate-modulating strategies; however, the ineffectiveness of other N-methyl-D-aspartate (NMDA) antagonists suggests that any forthcoming advances will depend on improving our understanding of ketamines mechanism of action. The fleeting nature of ketamines therapeutic benefit, coupled with its potential for abuse and neurotoxicity, suggest that its use in the clinical setting warrants caution. The literature indicates there are risks associated with this treatment. Colleagues noted damage to the urinary barrier initiates bladder pain and, in ketamine-induced cystitis, loss of urothelium from large areas of the bladder wall is a reported feature. This study offers first evidence for a mechanism of direct toxicity of ketamine to urothelial cells by activating the intrinsic apoptotic pathway. In sum, there is a lack of support for the requested medication in this clinical setting. Therefore, the requested ketamine infusions 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 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

The patient is a 34-year-old man with a long history of tinea pedis and onychomycosis. He has requested authorization for Gris-Peg for treatment of his condition. The patient is not otherwise immunocompromised or with significant medical disease. The Health Plan has determined that Gris-Peg is not medically necessary for treatment of the patients medical condition.Antifungal agents for treatment of onychomycosis are not medically necessary unless there is evidence of a positive culture and documentation of severe impairment, dysfunction or comorbidity. In this case, evidence of a positive culture has not been provided. In the absence of documentation of a fungal infection the requested medication is not medically indicated. Therefore, I have determined that the requested medication is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 28-year-old male enrollee has requested coverage for Provigil 200mg for treatment of his schizoaffective disorder, bipolar type.  Findings:  The physician reviewer found that the requested medication is not medically indicated for the treatment of this patient.  The risk-benefit ratio is questionable, as this medication can trigger a manic episode.  Additionally, this patient has a history of stimulant abuse. American Psychiatric Association guidelines for bipolar disorder and schizophrenia do not indicate adjunctive use of stimulants. The current medical evidence does not support the requested medication in this patients case.  In sum, the data reviewed fails to support the use of Provigil in this clinical situation.  Current evidence-based standards of medical practice and expert consensus do not support the use of Provigil in this case.  All told, Provigil 200mg is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Picato for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. This patient has a history of facial basal cell carcinoma.  His occupation involves performing procedures which produce a non-sterile environment.  Treatment with Picato gel is preferred due to the limited downtime associated with the treatment.  Picato gel is a U.S. Food and Drug Administration (FDA) approved three-day treatment for actinic keratosis.  The first-line therapy typically involves a 21-day course of therapy.  Significant cutaneous inflammation is associated with use of these medications.  As the patient is considered to be at risk for airborne infectious exposures due to his occupation, a concise treatment period is appropriate.  All told, Picato 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services.  The American Society of Addiction Medicine (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. According to the ASAM guidelines for treatment, a patient should be placed in a 3.7 medically monitored intensive inpatient withdrawal management when signs and symptoms are sufficiently severe to required 24-hour inpatient care, and remain until withdrawal signs and symptoms are sufficiently resolved that he can be safely managed at a less intensive level of care. In this case, the patient did not reach moderate to severe withdrawal status. The patient required treatment for withdrawal management, consistent with dimension 1. However, the records document that his withdrawal symptoms had resolved, without medical or psychiatric complications. The patient did not meet the criteria for dimension 2 given the lack of a biomedical condition or continued drug use placing the patient at significant risk to his physical health. In addition, the patient did not meet dimension 3, as there was no documentation of an unstable psychiatric condition interfering with his abstinence, recovery, or stability. For dimension 4, the patient remained in the contemplative state of change and his provider recommended continued outpatient treatment with AA services. For dimension 5, the patient remained at risk for relapse given his lengthy history of substance use and difficulty in maintaining sobriety. The patients recovery environment was noted to include his wife, who has been negatively affected by his substance abuse. Given these findings, the patient does not meet all of the required dimensions for RTC level of care services. Accordingly, the RTC services were not medically necessary for 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 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: Medical Necessity
Decision: Upheld

A 24-year-old female enrollee has requested for partial hospitalization program (PHP) for treatment of her bulimia, depression and alcohol abuse. Findings:  The physician reviewer found that although the patient unquestionably suffers from Bulimia Nervosa and obsesses about her body image, her binging and purging as well as obsessing had diminished.  Given her compliance, improvement and regular attendance to treatment throughout, both in terms of the various therapies as well as the medication she was prescribed, it is not clear why transition to Outpatient Treatment couldnt have been considered by this point.  Based upon review of all the information submitted there is no evidence to document the necessity of Partial Hospitalization.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for The Centers for Disease Control and Prevention (CDC) guidelines state that clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. The Federation of State Medical Boards guidelines state: Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion.In this case, the patient has been on chronic opioid therapy with Norco twice daily as needed for chronic pain related to failed right shoulder surgery and poorly healed forearm fracture with residual nerve damage. The records noted that the patients urine drug screen was positive for THC. The patient states that she has been using over-the-counter CBD oils as a balm for her pain. The patient has a psychiatric history notable for depression, anxiety, and a personality disorder. The physician reviewer found that conditions can increase the risk of inappropriate use and related side effects of opioid medications. In addition, the THC content in over-the-counter CBD products is variable. The CDC and the Federation of State Medical Board do not support the concurrent use of opioids with THC. Based on the available records for review and the current national guidelines, the requested hydrocodone/acetaminophen (Norco) 10/325 mg at one tablet twice daily is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services provided for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that according to the documentation submitted for review this patient could have been treated at a lower level of care. According to colleagues treatment at the PHP level of care is appropriate when meal supervision is needed without requirement for 24-hour supervision. PHP admission generally requires that patients be at or above minimally acceptable weight such as greater or equal to 80% of ideal body weight and maintain other evidence of medical stability. In this case, the patient was medically stable. Her laboratory work-up was unremarkable. Her sodium, potassium, chloride, liver function tests, and albumin were all within normal limits. The patient weighed 101 pounds. Her ideal body weight is 125 pounds. She was above 80% of her ideal body weight. She did not require 24-hour observation for any medical problems. The patient did not have any suicidal or homicidal ideation. The patient did not have any psychosis, hallucinations, or paranoia that would require 24-hour observation. The patient was motivated for treatment. In addition, the standard of care is to treat patients in the least restrictive environment possible. For the reasons provided, the patient could have been treated in a less restrictive environment. Final Result: The reviewer determined that the services at issue were not and 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 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 reimbursement for inpatient skilled nursing facility (SNF) services and physical therapy, occupational therapy, and speech therapy services provided at Broadway by the Sea. Functional impairments due to acquired brain insults such as stroke can be severe to profound. One researcher notes that rehabilitation is an important aspect of the continuum of care in strokes, and that successful rehabilitation involves understanding the natural history of stroke recovery and a multidisciplinary approach to identify and treat common poststroke sequelae. A researcher notes that patients may improve spontaneously within the first three months and then more slowly in the coming year. Rehabilitation services are rendered first in the inpatient setting, followed by rehabilitation in the community setting if still indicated, based on impairments and the potential for achieving practical, functional goals. Rehabilitation efforts are indicated at a level of intensity commensurate with deficits until care can be safely and effectively transitioned to a less intensive level of care. In this case, the patient sustained an ischemic stroke in the distribution of the right middle cerebral artery, resulting in severe to profound deficits affecting multiple domains, including motor speech, swallowing, self-care and basic mobility.  She made slow but steady gains with multidisciplinary rehabilitation, with clinically significant gains in dressing, substantive gains in transfers, major gains in ambulation, and major gains in swallowing ability.  Given that these gains could not have been achieved in a safe and efficient  manner without the aid of therapists, the services at issue were medically indicated. Therefore, inpatient SNF services and physical therapy, occupational therapy, and speech therapy services provided at Broadway by the Sea were medically necessary for the 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested Peg-Intron for the treatment of her hepatitis C. Findings:  The physician reviewer found that there is no literature that demonstrates Peg-Intron is superior to Pegasys in terms of efficacy or side effects. Pegasys uses a different molecule than Peg-Intron, with different pharmacokinetics, and adjustments based on weight are unnecessary. There are no apparent contraindications to treatment with Pegasys.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee has requested for Actiq for treatment of her buttock and lower extremity pain. Findings:  The physician reviewer found that Actiq is currently approved by the FDA for the management of opioid recalcitrant, cancer related, breakthrough pain. The medication has not been approved for the management of chronic post-operative abdominal pain with adhesions. The use of Actiq in this context is not medically indicated and is not consistent with the community standard of care.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patient has requested authorization and coverage for spinal injections. In a study of the effectiveness of lumbar facet joint blocks, Cohen and colleagues report that therapeutic facet injections appear to have little long-term utility, and 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. The authors concluded  that facet blocks are not therapeutic and that higher responder rates in the treatment groups suggest a hypothesis that facet blocks might provide prognostic value before radiofrequency ablation. Kwak and colleagues report that intraarticular lumbar facet joint corticosteroid injection treatment may be effective, regardless of facet joint osteoarthritis severity. The authors note that while intraarticular lumbar facet joint corticosteroid injections may be a useful clinical option for the management of facet joint osteoarthritis mediated low back pain, the present study was limited by its retrospective design and relatively small sample size, and that further studies are required on the long-term effects of intraarticular lumbar facet joint corticosteroid injection. The authors did not evaluate the long-term effects of intra-articular lumbar facet joint corticosteroid injections. In this case, the patient presented with constant, unchanged, and severe back pain that was described as stabbing and rated at an eight to ten out of ten on average. The patient reported increased pain with lying down, sitting, bending, twisting, and household chores. The patient had recently completed physical therapy with mild effect. An examination revealed severe tenderness at the lower lumbar spine L3-S1 and bilateral sciatic nerves, a moderately decreased lumbar range of motion, positive Kemps tests bilaterally, and intact strength, sensation, and reflexes. However, magnetic resonance imaging (MRI) did not provide detailed documentation regarding facet pathology. While the records noted that x-rays showed facet hypertrophy at L4-5 and L5-S1, formal x-ray reports were not provided for review despite being requested. Given the limited nature of published, large-scale, long-term peer-reviewed literature supporting the requested service as an effective and/or safe treatment for the noted pathology, the requested service is not medically indicated. Therefore, spinal injections 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.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested authorization and coverage for BRCA testing.  The health plan has denied this request indicating that the requested genetic testing is not medically necessary for treatment of the enrollees breast cancer.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested BRCA testing is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication, Simponi 100 mg every 14 days. The enrollee has a history of ulcerative colitis pancolitis. The injectable medication Simponi, 100mg every 14 days has been prescribed.  The record indicates the enrollees condition is difficult to control.  He has been receiving Simponi every four weeks, but it was only effective for two weeks.  He would have two solid bowel movements daily for the first two weeks. By weeks three and four he had up to three to four bowel movements daily, with blood.  The enrollee has long-standing ulcerative colitis with active disease, despite treatment with four different biologic agents and with intolerance to immunosuppressive drugs, except for prednisone.  A progress note indicates a colonoscopy showed active pancolitis with rectal sparing.  The provider recommended the patient continue Simponi and escalate the dose to every two weeks. The record indicates overall improvement with Simponi, but the patient was concerned because he had experienced increased symptoms prior to the next injection.This enrollees symptoms are poorly controlled with the current dosage regimen of every four weeks.  CellCept was stopped due to elevated liver function tests (LFTs). The failure of alternative treatments warrants off-label dosing under the care and guidance of his provider. The Simponi prescribing information notes the indications for use include achieving and sustaining clinical remission and that it has demonstrated efficacy in refractory ulcerative colitis in phase 2/3 studies. A study indicates treatment with subcutaneous golimumab induces clinical response, remission, and mucosal healing.  It results in an increased quality of life in larger percentages than placebo. In a follow-up study, golimumab maintained a clinical response through week 54 in patients with moderate-to-severe active ulcerative colitis who responded to induction therapy. Patients who received 100 mg golimumab had clinical remission and mucosal healing at weeks 30 and 54.                                                          Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old female enrollee has requested Intravenous Immune Globulin Therapy for the treatment of her multiple sclerosis. Findings:  The physician reviewer found that this patient has a history consistent with relapsing remitting multiple sclerosis (RRMS), now progressive. Prior treatments with Betaseron, Cellcept and methotrexate have not been effective. Novantrone has not been considered a clinically appropriate option for this patient. IVIG treatments have been successful for over 2 years and are accepted as a second line therapy for multiple sclerosis. IVIG should be continued as treatment for this patients multiple sclerosis.