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

A 65-year-old male enrollee has requested skilled nursing facility services for treatment of his congestive heart failure, chronic scrotal hernia, hypertension, lymphedema, neuropathy, obesity and peripheral vascular disease.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient has been in the inpatient rehabilitation setting for a prolonged period of time with chronic conditions, including obesity, scrotal hernia and leg edema.  Per the medical records, the patient has not been motivated to perform basic self-care or activities of daily living.  As of the date indicated, there has been no significant functional progress.  There is no active wound care, nursing or medical issue requiring ongoing inpatient care.  He has completed treatment for urinary tract infection and pneumonia.  From the date indicated forward, his care is custodial in nature and not medically necessary at a skilled nursing facility level of care.  The records do not support a reasonable likelihood of significant health or functional gains with ongoing care in this setting.  The medical literature does not support the necessity of this intervention in the absence of demonstrated and expected function progress.  All told, skilled nursing facility services (including physical therapy)  from the date indicated forward were not and are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The representative of a 22-year-old male enrollee has requested acute inpatient psychiatric care for treatment of his mental condition. Findings:  The physician reviewer found that although well developed clinical guidelines and patient placement criteria provide assistance, determination of the appropriate length of stay for a patient with a severe formal thought disorder complicated by co-occurring anxiety and substance use disorders, poses a significant challenge for inpatient treatment providers. The patients records support the necessity of previous treatment. However, the records do not support continued treatment at the acute level of care. Prior to the date indicated, the patient had demonstrated poor insight. Additionally, he had threatened staff such that care providers had to be notified of specific threats. He was plagued by intrusive thoughts and subsequent repetitive behaviors, yet was resistant to taking medication for obsessive compulsive disorder. On the date indicated, fluoxetine was started for the patients anxiety. On a the subsequent date indicated, he was not suicidal, homicidal or psychotic per the providers note. On the date indicated, the patient posed no danger to himself or others while the discharge plan was adjusted. Based on the documentation provided, and considering the case in its entirety and the relevant peer reviewed literature, the requested continuation for acute inpatient psychiatric treatment level of care services is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Xeljanz XR 11 mg tablets. Xeljanz is U.S. Food and Drug Administration (FDA) approved for the treatment of psoriatic arthritis in patients who are unable to take a tumor necrosis factor (TNF) inhibitor, or prefer an oral medication. In this case, the patient has failed a TNF inhibitor and has anti-nuclear antibodies. Thus, treatment with a TNF inhibitor is not recommended. The records also document that treatment with methotrexate, sulfasalazine, and Otezla were not substantially effective. Her psoriatic arthritis is not severe enough to support treatment with Cosentyx or Stelara. Given these findings, the requested Xeljanz XR 11 mg tablets 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. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in allergy and immunology and rheumatology 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 intravenous immunoglobulin (IVIG) therapy for treatment of her medical condition.   Findings:  The physician reviewer found that there is limited literature to indicate that painful neuropathy in patients with diabetes can be effectively treated with IVIG. This patient is documented to have painful polyneuropathy, supported by exam and referenced by an electromyogram (EMG) but painful polyneuropathy is a common complication of diabetes and may not be indicative of chronic inflammatory demyelinating polyneuropathy (CIDP). The cerebrospinal fluid (CSF) features associated with CIDP would typically include elevated protein, normal cellularity which were not reported for this patient. Also, there is no mention of the typical EMG findings associated with stiff person syndrome (SPS) and there is no rigidity reported. Anti-GAD (Glutamic Acid Decarboxylase) antibodies are seen in patients with type 1 diabetes in up to 80% without SPS, in but a small fraction. First line therapy for neuropathic pain typically includes gabapentin, Lyrica, and tricyclic medications such as amitriptyline. Based on the records provided, it does not appear the patient has exhausted first line therapies for treatment of her neuropathic pain. All told, the requested IVIG therapy is not medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the requested therapy 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 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 46-year-old female enrollee has requested authorization and coverage for the prescription medication Subutex (or Suboxone) for treatment of her opiate dependence. Findings:  The physician reviewer found that the patient recognized her opiate dependence and began treatment with a specialist in the field of addiction medicine. Subutex was prescribed to assist her with detoxification from opiate pain medications. In this instance, Subutex has been used specifically for the treatment of opiate addiction, which is the intended purpose of this medication.
Appeal type: Experimental/Investigational
Decision: Upheld

A 20-year-old female enrollee has requested hip surgery (hip arthroscopy CPT 29916) for treatment of her hip pain and labral tear.  Findings:  Two physician reviewers found that medical literature and guidelines support the requested surgical procedure when specific criteria have been met. The criteria includes, hip pain, diagnosis of femoroacetabular impingement syndrome (FAIS) with evidence of cam impingement (alpha angle greater than 50 degrees), failure of conservative therapy for at least six months, activity modification, treatment with non-steroidal anti-inflammatory drugs (NSAIDS) or acetaminophen, no other explanation for pain and the individual has minimal degenerative changes of the hip joint (Tonnis grade 1 or less). Medical guidelines recommend a trial of conservative care to be initiated first as patients will often improve over time. In this particular case, there is no evidence of conservative care being initiated or of the patients response to conservative modalities. Therefore, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapies.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for skilled nursing facility level of care for treatment of the enrollees skin condition. Findings:  The physician reviewer found that the medical literature indicates that inflammatory demyelinating polyneuropathies are well known to cause significant functional impairments. The chronic variants are known to cause fatigue and have a progressive course lasting months, affecting participation in rehabilitation efforts and functional recovery. In this patients case, the patient had had a slow recovery following his initial collapse.  His functional status had plateaued to the point that further care at a custodial level was recommended. Prior to an initial discharge for late November 2016, there were incidental indications of a rash, possibly pruritic. However, the documentation shows no indication that the rash was severe or medically concerning. A providers note on 12/7/16 indicated a skin examination that was within normal limits.  On 12/8/16, a providers record noted some mild rash and orders were written for a lotion to be applied daily due to dry skin and anti-itching medication to be administered as needed. There were no indications that this rash was significant enough to warrant further investigation. There were no referrals made for a dermatology consultation and no documentation that the rash required more significant treatment. There is a lack of clinical documentation supporting a delay in discharge from the facility. 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 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: Overturned

A 41-year-old male enrollee has requested Lyrica for the treatment of his neuropathic pain. Findings:  The physician reviewer found that the use of Lyrica is commonplace as an adjunct to monotherapy with narcotic medication and is useful in many painful conditions. The traditional U.S. Food and Drug Administration (FDA) indications for Lyrica include painful neuropathy from diabetes and post-herpetic neuralgia, as well as fibromyalgia. As noted by OConnor and Dworkin, there are many clinical studies that have demonstrated the benefits of Lyrica for neuropathic pain, chronic pain and post-operative pain. In practice, Lyrica is used quite frequently for management of patients with severe chronic pain. With regard to this patient, there is documentation of several years of good results with Lyrica as part of a stable low-dose narcotic regimen that seems to be very effective. In addition, he has been intolerant of several other medications including gabapentin and thus was started on the Lyrica. As he experiences no side effects and good pain relief, there is adequate rationale to continue the requested medication. After reviewing the medical literature, applying the standard of care, and taking special consideration of all aspects of this patients medical history, Lyrica is medically indicated for the management of this patients chronic pain.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for testosterone gel, 1%. The enrollee has a medical history of solar urticaria, hidradenitis suppurativa, and obesity. Blood work showed a low total testosterone level below the normal range of 250 to 827. His provider reviewed the laboratory results and diagnosed the enrollee with testicular hypofunction, secondary to obesity. Weight loss for fat reduction and muscle building was discussed. AndroGel was prescribed. The enrollee indicates one of the side effects of low testosterone is its affects on the brain, which can lead to anxiety or depression. He reports he now feels depressed, upset and angry. Testosterone gel, 1%, is an androgen indicated for replacement therapy in adult males for conditions associated with a deficiency or absence of endogenous testosterone. Professional society practice guidelines indicate testosterone should be administered only to an adult male who is hypogonadal, as evidenced by clinical symptoms consistent with androgen deficiency, and a subnormal morning serum testosterone concentration documented on three separate occasions. Symptoms of androgen deficiency include low libido, decreased morning erections, loss of body hair, low bone mineral density, gynecomastia, and small testes. The beneficial effects of testosterone in these men are clear, and they should be treated with testosterone to raise their serum testosterone concentrations to normal. Symptoms of fatigue, depression, anemia, reduced muscle strength, and increased fat mass are less specific. The record does not have sufficient clinical/laboratory criteria to define hypogonadism, such as two separate sub-normal serum testosterone levels, drawn in the early morning, on two separate occasions at least two weeks apart. An abnormal serum testosterone value was not confirmed with a second morning testosterone measurement, along with luteinizing hormone and follicle-stimulating hormone to help determine if the has testicular hypogonadism or hypothalamic-pituitary hypogonadism.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 reproductive endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bariatric surgery. Findings:  The physician reviewer found that, based on the documentation submitted for review, the request for bariatric surgery is not medically necessary. The patient does not meet standard criteria for bariatric surgery for failure to document morbid obesity with a BMI of 40, or a BMI of 35 or greater that is associated with serious obesity co-morbid conditions such as diabetes, hypertension or sleep apnea. The patient has no documented history of any serious obesity co-morbid condition with a BMI that is 35.96 kg/m2. As such, the medical necessity for the requested surgery is indicated for in this clinical setting. Final Result: The reviewer determined that the requested surgery 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 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency department (ED) services provided on 4/11/16.Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The emergency department services provided on 4/11/16 were not necessary for treatment of an emergency medical condition. In this case, the patient presented with generalized weakness and a burning sensation throughout her body for many months. Although she admitted to shortness of breath, this had been minor and intermittent. The patient was minimally tachycardic on arrival and this resolved without treatment. She had already been evaluated by her primary care provider earlier that day. Given that the patients symptoms were not sudden or acute in onset, the services in dispute do not constitute emergency services.  Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in emergency 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 41-year-old male who suffers from severe Acne Rosacea requested authorization and coverage for photoderm laser treatment.  The Independent Medical Review determined that the service was medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old female enrollee has requested 4-aminopyridine for the treatment of her multiple sclerosis. Findings:  Three physician reviewers found that there is adequate medical literature supporting the use of 4-aminopyridine for patients with multiple sclerosis who have walking disability. Husseini and colleagues reported on a randomized, placebo-controlled, multicenter Phase 3 clinical trial of multiple sclerosis patients. The authors noted that mobility limitation is a frequent clinical symptom of multiple sclerosis which poses a therapeutic challenge. 4-aminopyridine improved axonal excitatory circuits and thus muscular strength in demyelinating diseases. The authors concluded that the study results showed 4-aminopyridine represents a suitable agent for treatment of walking disability in multiple sclerosis patients. This patient has multiple sclerosis and difficulty ambulating. Thus, she is an appropriate candidate for 4-aminopyridine therapy. There are no alternatives available that are likely to result in a better functional outcome for the patient than 4-aminopyridine.
Appeal type: Experimental/Investigational
Decision: Overturned

A 64-year-old female enrollee has requested ultrasound guided chemical vein treatment (sclerotherapy) and its associated services for treatment of her varicose veins.  Findings:  Three physician reviewers found that ultrasound-guided foam sclerotherapy shows success rates varying from 82% to 100% and can eradicate reflux in the above knee and below knee greater saphenous vein in over 95% of patients with symptomatic primary great saphenous varicose veins. This treatment leads to significant improvement in health related quality of life for at least 12 months after treatment.  Given the studies published to date, there is sufficient medical evidence supporting the requested services in this clinical scenario.  In this patients case, the requested ultrasound guided chemical vein treatment (sclerotherapy) and its associated services are likely to be more beneficial than other available treatments.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS). The American Psychiatric Association (APA) guidelines state that the acute phase of treatment for depression may include TMS. TMS is U.S. Food and Drug Administration (FDA) approved for the treatment of treatment-resistant major depressive disorder. George and colleagues found that TMS is significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. Connolly and colleagues reported that TMS was safe and effective in both acute and maintenance treatment of patients with treatment resistant depression. Tarhan and colleagues reported that TMS was well tolerated and found to be statistically and clinically effective in patients with treatment resistant depression. The physician reviewer found that records provided for review support that this patients depression is treatment resistant. He has failed treatment with multiple antidepressants and augmentation strategies, as well as psychotherapy. Given these findings, the requested TMS is medically necessary for treatment of this patient.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.
Appeal type: Medical Necessity
Decision: Overturned

A 30-year-old female enrollee requested assessment and medication management by an adult cardiologist who specializes in the treatment of congenital heart disorders and defects and continued cardiac electro-physiology studies performed by a cardiology specialist familiar with the enrollees complex heart defects, two valve replacements and pacemaker implantation for medica; treatment of her medical condition.  Findings:  The physician reviewer found that given the complexity of her medical problems, she is best managed by a cardiologist specializing in adult congenital heart disease.  The patient is status post multiple surgical procedures, including aortic valve replacement, mitral valve replacement and pacemaker placement.  She is at an increased risk for future cardiovascular complications.  All told, continued assessment and medication management by an adult cardiologist who specializes in the treatment of congenital heart disorders and defects and continued cardiac electro-physiology studies performed by a cardiology specialist familiar with the patients complex heart defects, two valve replacements and pacemaker implantation are medically indicated for treatment of this patient.