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

The father of a five-week-old male enrollee has requested for transfer to an out-of-network Level 4 Neonatal Intensive Care Unit (NICU) for treatment of the enrollees multiple medical problems secondary to severe prematurity. Findings:  The physician reviewer found that although pediatricians provide good coverage, it is standard of care for neonatologists to attend a triplet delivery and to cover high acuity patients. For such a patient, neonatology coverage should be available on site, on a 24-hour basis. A patient such as this one should be managed in a level 4 NICU with sub-specialty coverage and high acuity equipment such as high frequency ventilators and ECHMO available. In general, the transfer of a five-week old premature infant is feasible if the receiving facility has accepted the patient, the proper equipment and medical coverage are available at the receiving facility and the patient is stable for transport.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old male enrollee requested physical therapy (1-2 times per week for 6 weeks) for medical treatment of his chronic back pain.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested therapy. Physical therapy is a widely used treatment for low back pain. The duration and frequency of treatment are not adequately addressed in the medical literature. A recent set of PT guidelines by Delitto and colleagues indicates there is a benefit to therapeutic exercise tailored to the patients condition. In this case, the patient noted improvement in PT, but when the formal sessions were stopped his pain increased. Skilled physical therapy services with provision of pain relieving modalities such as hot packs and TENS unit are not a long-term maintenance type of treatment. Hot packs and TENS unit can be self-administered as can a home exercise program, the latter of which is the object of PT. Therefore, a limited number of physical therapy sessions to develop a home exercise program is clinically indicated. As such, the requested therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested prescription medication Ambien 10mg tablet for treatment of her insomnia.  Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. According to the U.S. Food and Drug Administration (FDA), label changes have been approved specifying new dosing recommendations for zolpidem products because of the known risk of next-morning impairment with these drugs. The recommended initial dose of certain immediate-release zolpidem products (Ambien and Edluar) is 5mg for women. The recommended initial dose of zolpidem extended-release (Ambien CR) is 6.25 mg for women. Although the lowered recommended dose of zolpidem is a recommendation and clinical exceptions can be made, higher doses such as the requested dose of 10mg in women are associated with increased risk of daytime impairment. Furthermore, zolpidem is not intended for chronic use as it can result in dependence. As such, the requested Ambien 10mg tablet is not considered medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 63-year-old male with a body mass index (BMI) of 42.4. The patient has significant comorbidities. The patient reports multiple failed attempts at diets, all of which have resulted in weight regain. The patient has undergone a psychological evaluation and has obtained clearance for weight loss surgery. The patients provider has recommended the patient undergo gastric bypass with duodenal switch. The Health Plan indicates the long-term safety and efficacy of the procedure has not been established.The patient is an appropriate candidate for surgical intervention to treat his morbid obesity. There is more than substantial data in the literature to support the use of duodenal switch to accomplish this goal. Consequently, duodenal switch is an accepted and medically necessary procedure for this patients medical condition. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 54-year-old male enrollee has requested sacroiliac joint radiofrequency ablation using the synergy technique for treatment of his pain. Findings:  Two physician reviewers found that the current medical evidence supports the requested services in this clinical scenario. This patient had a comprehensive diagnostic workup.  He was denervated via the synergy technique, with reported pain reduction. The fact that his pain is recurring after a long absence is an indicator of a sacroiliac dysfunctional pain generator. These services aided in the management of this patients severe chronic pain. The current medical literature supports the requested services as a safe and effective treatment.  All told, the requested radiofrequency ablation using the synergy technique is likely to be superior over other available treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee has requested Reclast injections for the treatment of her osteoporosis. Findings:  The physician reviewer found that the patient has failed objective response in her spine to three bisphosphonates. There is no evidence in the literature or current rationale that would suggest she would respond to another bisphosphonate orally (Boniva) or intravenously (Reclast) better than those previously failed. In any case, the bisphosphonates will not work if she is unable to absorb calcium. She appears to be treated with suboptimal doses of vitamin D. She is taking a medication (Cytomel) that is potentially bone toxic. There are two good alternatives (Evista, and Forteo) and one fair to poor alternative (nasal calcitonin). However, they also will not work without adequate intake of calcium with vitamin D. The requested therapy is not medically warranted for treatment of this patient.
Appeal type: Urgent Care
Decision: Overturned

A 50-year-old male enrollee has requested emergency services for the treatment of his medical emergency. Findings:  The physician reviewer found that the symptoms of difficulty breathing and persistent coughing are consistent with a variety of potentially life-threatening emergent medical conditions including exacerbation of asthma, pneumothorax, pneumonia, and other respiratory and cardiac disorders. Given that these symptoms were new to the patient and that he had no prior history of respiratory difficulties, it is reasonable for a prudent layperson to access emergency medical care for such symptoms.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a seven-year-old male enrollee requested authorization and coverage of speech therapy. The Health Plan denied this request indicating that the requested services are not medically necessary for treatment of the enrollees speech delay.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 61-year-old female who is seeking authorization for continued outpatient therapy. The patients therapist has provided a list of the patients symptoms including hopelessness, social withdrawal, and increased anger. The patient has been receiving outpatient therapy for approximately three years. The Health Plan has denied authorization for continued therapy.Based upon the information provided, the Health Plan has approved 88 therapy sessions for the patient over the last three years. No physician records or progress notes have been submitted. The patients therapist has not indicated the patient is psychotic or suicidal or having difficulty with a medication regimen. In addition, it appears the patient is functional, employed, and able to work. No information has been submitted that demonstrates ongoing therapy is necessary. 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: Experimental/Investigational
Decision: Upheld

A 48-year-old female enrollee has requested a PET/CT, skull base to mid-thigh for evaluation of her history of breast cancer. Findings:  Three physician reviewers found that the patient currently has no symptoms or physical findings to suggest recurrent or metastatic breast cancer.  PET/CT scans are utilized as an adjunct to conventional imaging in select patients with a personal history of breast cancer.  This diagnostic procedure is mainly utilized for patients with suspected loco-regional recurrence or those patients with suspected distant metastatic disease. The National Comprehensive Cancer Network guidelines do not recommend the use of PET/CT scans for surveillance purposes in patients with a personal history of breast cancer.  As this patient does not have clinical evidence of suspected loco-regional recurrence or suspected distant metastatic disease and is not currently undergoing chemotherapy, the requested diagnostic procedure is not likely to be superior over other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 61-year-old woman with hypertension, JNC Stage I. She was treated in the past with Diltiazem XR 240 mgm. The patients provider subsequently prescribed Hyzaar 50/12.5, which has been well tolerated. The Health Plan has denied coverage for Hyzaar on the basis it is not medically necessary as there are formulary ARB/HCT medications available to the patient. The Health Plans denial should be upheld. The medical records do not demonstrate that the patient has tried and failed the formulary ARB/HCT medications offered by the Health Plan. There is no scientific medical data to support the preferential use of Hyzaar over Benicar HCT or Diovan HCT. As such, there is no medical indication for use of Hyzaar at this time. Therefore, I have determined the requested medication 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: An enrollee has requested authorization and coverage for Sovaldi for 12 weeks for treatment of her hepatitis C virus. Findings:  The physician reviewer found that according to the joint guidelines from the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Per the AASLD/IDSA guidelines, daily sofosbuvir (Sovaldi) and weight-based ribavirin for 12 weeks is recommended for treatment-naive patients with hepatitis C genotype 2. As such, the requested treatment is medically necessary and is considered the standard of care for the treatment of the patients with hepatitis C genotype 2. 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 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: Upheld

An 18-year-old male enrollee has requested for residential treatment for treatment of his major depressive disorder, oppositional defiant disorder and cannabis abuse. Findings:  The physician reviewer found that he manifested no suicidal or homicidal ideation or behaviors. He did not attempt to elope, and even when placed on precautions, there were not elopement behaviors. Medication management was uncomplicated as the patient tolerated the dosage increases and showed no side effects.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for OnabotulinumtoxinA (Botox) injections. The enrollee has daily headaches, secondary to migraine headache without aura, and right occipital neuralgia. Previous medication trials have not been effective. The provider reports the enrollees headache frequency was previously 15-17 days per month. While being treated with onabotulinumtoxinA (Botox) and Aimovig, the enrollee is having seven headache days per month and an improved quality of life. Because Aimovig is relatively new, there does not appear to be any peer-reviewed literature specifically addressing the combination of onabotulinumtoxinA (Botox) and Aimovig.  However, current clinical practice is to add a drug such as Aimovig to a migraine enrollees current anti-migraine regimen. This enrollees neurologist reports the enrollee has failed many other anti-headache agents and requires both Botox and Aimovig for headache control. Additionally, the Headache Society reports that certain properties of the Aimovig drug class enables individuals to avoid interactions with other drugs, and this drug class may be added to, or used in conjunction with, other oral or injectable preventive treatments for migraine.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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 28-year-old female enrollee has requested authorization and coverage for intravenous (IV) antibiotic therapy (with home health skilled nursing care for treatment of the enrollees chronic Lyme disease.  Three physician reviewers found that a portion of the therapy at issue was  medically necessary, stating that this case does not demonstrate convincing evidence for the presence of late-stage Lyme disease or babesiosis. However, considering the uncertainties of medicine, authorization of one four-week course of IV antibiotic therapy is clinically reasonable. Any additional antibiotic courses, oral or intravenous, for any time period should be denied.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient psychiatric hospital services. Findings: The physician reviewer found that although the patient has a severe formal thought disorder that will require long-term specialty care, the records provided for review do not demonstrate the medical necessity for services at the acute inpatient level of care during the disputed timeframe. Per psychiatry notes, the patient was tolerating her psychotropic medication which consisted of both an antipsychotic and antidepressant. The patients mood was good, her thought process was goal directed, and she had no suicidal ideation. She was cognitively intact. She was neither delusional nor psychotic and she was engaged in treatment. Her laboratory monitoring for clozapine therapy was stable, and earlier episodes of bradycardia and orthostatic syncope had resolved. Overall, there is a lack of evidence to suggest that transition to a less restrictive setting would have compromised the patients safety or misaligned with reasonable practice standards. 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 the monitored anesthesia care (MAC) provided for evaluation of the enrollees screening for malignant neoplasm.Findings: The physician reviewer found that the patient has an ASA preoperative physical status classification score of 1. Intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well supported in both clinical practice and in the research given the patients low preoperative physical status classification score (Heuss, et al; Trummel; Saenz-Lopez, et al; Fanti and Testoni). For these reasons, the MAC service provided were not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the service at issue was not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee has requested a cold therapy unit and external infusion pump for post-operative recovery. Findings:  The physician reviewer found that there is inadequate literature to support the use of a cold therapy unit following rotator cuff surgery. There is no available data demonstrating that cryotherapy is more effective than the application of ice packs. No long-term data exists showing that cold therapy units result in improved outcomes in this clinical setting. Furthermore, the use of an external infusion pump was not medically necessary based on the information provided. Standard pain management modalities would have been sufficient in this case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance imaging for evaluation of the enrollee, who reported a history of neck pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The American College of Radiology guidelines do not support magnetic resonance imaging in this clinical setting. It is well-known that abnormalities detected on magnetic resonance imaging of the spine do not necessarily correlate with symptoms.  There are innumerable patients who are relatively asymptomatic, but have significant abnormalities on magnetic resonance imaging. The physical examination is generally more important than magnetic resonance imaging findings. Researchers reported the examiner should avoid overreliance on medical technology in making their assessment because this approach is fraught with false-positive and false-negative pitfalls that may be harmful to the patient. The current medical evidence does not support the services at issue in this patient. This patient has a history of neck pain. However, a trial of intensive anti-inflammatory medications as well as physical therapy and other conservative measures is warranted before magnetic resonance imaging is performed. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for of 35 hours per week of one-on-one applied behavioral analysis (ABA) therapy for treatment of his autism. Findings:  The physician reviewer found that the request for 35 hours per week of one-on-one ABA therapy, is medically necessary for treatment of the patients medical condition. Researchers studied 726 children ages 1.5 to 12 years old receiving behavioral intervention services. The study indicated a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress. In this case, the patient has made progress, but he continues to have significantly problematic behaviors in the context of language delays and persistent vocal stereotypy. The patient is currently receiving 22 hours per week of direct one-one-one ABA therapy, which is less than what is typically recommended for optimal response. Several studies have recommended 25 or more hours of weekly ABA to ensure optimal outcomes. The Behavior Analyst Certification Board (BACB) state that typical comprehensive ABA programs range from 30-40 hours of treatment per week. In this clinical setting, the request for 35 hours per week of one-on-one ABA is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services at issue 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.