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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for diazepam (Valium) 2 mg tablet. In this case, the patient has chronic neck and back pain with a history of two neck surgeries. After her initial fusion surgery, she was treated with Valium in the immediate postoperative period, and then with Baclofen. Her medical records do not report that the patient has attempted treatment with other muscle relaxants. The current medical literature indicates that there is a lack of evidence demonstrating that Valium is superior to other muscle relaxants for chronic pain or muscle spasms. There is evidence that chronic use of Valium carries increased risks of dependence and sedation compared to other medications in this class. All told, the requested diazepam (Valium) 2 mg tablet 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Tepezza infusions. Treatment with Tepezza for this patients exophthalmos is consistent with current medical literature recommendations based on the documentation supporting a diagnosis of dysthyroid orbitopathy and failure of steroid treatment. A study concluded that Tepezza for the treatment of active thyroid disease resulted in better outcomes with respect to proptosis, Clinical Activity Score, diplopia, and quality of life when compared to placebo without severe adverse events reported. Moreover, Tepezza has been shown to be beneficial and safe for patients with acute and active orbital inflammation related to dysthyroid orbital disease. The records show that the patients orbital inflammation is active despite treatment with steroids. Therefore, the requested Tepezza infusions 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 ophthalmology 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 male enrollee requested Harvoni 90/400 mg for medical treatment of his hepatitis C virus genotype 1a.  Findings:  Three physician reviewers found that 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, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions.  The requested medication is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested weekly individual therapy for medical treatment of her post-traumatic stress disorder (PTSD), depression, and anxiety.  Findings:  The physician reviewer found that the patients continuing behavior may represent an untreated underlying affective disorder with gross irritability. According to the medical literature, the value of psychotherapy in this setting is to get her to understand that her struggles are with her illnesses. Thus, weekly individual therapy should provide this patient with much needed support and is likely to facilitate continued progress. For these reasons, the requested weekly individual therapy is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for left lumbar radiofrequency ablation at L4-5 (CPT 64635). Researchers reviewed concluded that radiofrequency ablation was safe and effective for patients with facetogenic chronic low back pain. The authors noted that ideal patients with lumbar facetogenic chronic low back pain experienced greater than 80% relief of pain with two comparative lumbar medial branch blocks prior to radiofrequency ablation. Researchers concluded that there is Level II evidence demonstrating the long-term effectiveness of lumbar radiofrequency neurotomy and lumbar facet joint nerve blocks in well-selected patients. This patient presents with a four-month history of low back pain radiating into the hip and thigh. He reports functional limitations in his ability to perform activities of daily living and work duties. Clinical examination findings are consistent with facet-mediated pain, with no neurologic deficits. There is reported imaging evidence of disc degeneration and facet arthropathy at L4-5 and L5-S1, and annular tear at L5-S1. He has failed to improve with reasonable and comprehensive conservative treatment. He underwent a facet joint medial branch block at left L4-5 and L5-S1 with 60-70% improvement of his left-sided low back pain, which lasted approximately 12 hours. Current evidence based medical literature supported lumbar facet joint radiofrequency treatment as safe and effective for chronic facetogenic chronic low back pain when the patient experienced greater than 80% relief of pain with two comparative lumbar medial branch blocks. In this case, the patient has not demonstrated a response to medial branch block that meets current literature criteria and has not undergone two comparative lumbar medial branch blocks. The patient reported that he obtained about 12 hours of 60-70% improvement of his left-sided low back pain with one lumbar facet block. Therefore, the requested left lumbar radiofrequency ablation at L4-5 (CPT 64635) is not medically necessary for 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. 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: Experimental/Investigational
Decision: Upheld

A 56-year-old female enrollee has requested an MRI of the right breast for evaluation of her mass-like density in the upper outer right breast. Findings:  Three physician reviewers found that this patient has an enlarging mass-like density within the right breast in the area of a prior benign breast biopsy.  A diagnostic breast MRI has been requested for further evaluation. When a patient has a non-palpable mass that is suspicious, breast biopsy is the next appropriate study.  The use of breast MRI to avoid biopsy is not medically appropriate.  As noted by the American College of Radiology, MRI should not be used in lieu of biopsy of a mammographically, clinically, and/or sonographically suspicious finding.   Breast MRI is not meant to be a substitute for a breast biopsy.  Breast biopsy continues to be the gold standard for determining if a finding on physical examination, mammography and/or breast ultrasound is benign or malignant.  In conclusion, the requested MRI of the right breast is not likely to be superior over other available methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

A fifty-nine year-old male with a history of benign prostatic hypertrophy and an abnormal digital rectal exam is requesting authorization of proton beam therapy.Reviewers Findings:  The reviewing physician found that the current National Comprehensive Cancer Network Guidelines do not include proton beam irradiation as the standard of care.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested a panniculectomy for the treatment of her excess skin as a consequence of bariatric surgery. Findings:  The physician reviewer found that the submitted clinical evidence does not demonstrate that the requested surgery is medically necessary for this patient. No photographs were available for review. However, based on the clinical information provided, it does not appear that the amount of excess tissue involved is sufficient to cause the patients physical complaints. There is no objective evidence of a chronic functional problem that has failed to respond to conservative therapy. Furthermore, it does not appear the requested procedure is reconstructive in nature. The patient has generalized skin laxity consistent with her history of massive weight loss, which does not constitute an abnormal structure of the body.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 47-year-old man who has a thickened right first toenail, which cracks, disintegrates, and falls off with resultant pain. This limits the patients ability to exercise. Pathology examination in December 2004 of a nail segment revealed hyphae, i.e., fungus. The patient and his provider have requested authorization for Lamisil. The Health Plan has denied coverage for Lamisil on the basis it is not medically necessary for the patients condition.Analysis and Findings:The patient meets all medical necessity criteria for oral Lamisil treatment. He has had a consistent physical exam, laboratory confirmation, and a history of functional impairment, namely, pain with exercise. Lamisil is a medically appropriate and indicated treatment for patients such as this patient and therefore, should be authorized. Accordingly, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 7-year-old male enrollee has requested Daytrana 15 mg/9 hours daily patch for treatment of the enrollees attention deficit hyperactivity disorder (ADHD).  Findings:  The physician reviewer found that this patient has a documented diagnosis of ADHD and has been treated with multiple medications in the past. He has been tried on oral stimulants based upon amphetamines, oral stimulants based upon methylphenidate and the non-stimulant Strattera. He has had difficulties with side effects with insomnia, nausea, abdominal discomfort, and severe appetite disturbance. However, he has been treated for a month with a Daytrana 15 mg patch with improvement in academic performance and behavior. Clearly there is a marked difference in the metabolism of Daytrana that avoids many side effects for this patient. Perhaps it is the avoidance of irritation on the gastrointestinal (GI) system with the transdermal administration or perhaps it is the lower dosage required since the first pass is avoided. Ultimately, the transdermal administration of Daytrana changes the metabolism of this medication completely compared to its oral counterparts, in ways that make it tolerable for this patient. For these reasons, an oral methylphenidate is not an appropriate substitution for this patient and the requested Daytrana patch has been established as medically necessary for treatment of this patients ADHD and should therefore be approved.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee requested authorization and coverage of the medication Neupogen. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees neutropenia.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment at Hoag Memorial Hospital from the date of service in question, forward. Findings:  The physician reviewer found that the request for residential treatment center services provided from the date of service in question, forward were and are medically necessary for treatment of the patients medical condition. In general, the American Psychiatric Association provides the following guidance regarding the level of care decision process Residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. In this case, the patients alcoholism was central to his daily routine and contributed to his significant impairment across multiple domains of functionality. The patient has demonstrated minimal motivation for recovery. The patient was struggling with the concept of committing to long-term recovery, and the day before he was noted to be depressed and minimally social with a flat affect. As such, the patient has not yet consolidated the treatment gains necessary to succeed in an outpatient based treatment program. The services and setting were and are safe, appropriate and consistent with good practice, while the proposed duration of treatment aligns with community standards. Additionally, the services provided were and are reasonably expected to improve his condition and prevent a more serious episode of illness. In sum, considering the clinical presentation and peer-reviewed literature, the services at issue were and are medically necessary for treatment of the patients behavioral health condition. Final Result: The reviewer determined that the services at issue were and 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 67-year-old male enrollee has requested a series of Orthovisc injections to the right knee for treatment of his osteoarthritis. Findings:  The physician reviewer found that this patient previously received intra-articular viscosupplementation injections. The current medical evidence does not support the requested series of Orthovisc injections to the right knee at this time.  The requested injections are not likely to be beneficial in this clinical setting.  Double-blinded, well-designed, placebo-controlled studies have not demonstrated a clinical benefit for the requested services in this setting.  All told, the requested series of Orthovisc injections to the right knee is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a Guardant360 biopsy-free tumor sequencing test. The National Comprehensive Cancer Network (NCCN) guidelines for the treatment of breast cancer note that mutational testing for metastatic tumors may suggest some targeted therapies, and specifically mention liquid biopsies. Shimelis and colleagues report that patients with mutations identified by multigene hereditary cancer panel testing may benefit from specific targeted therapeutic strategies. PIK3CA is one such example. In most instances of visceral disease or lymph node involvement, testing may be performed on the excised tissue, however, in certain cases, such as bone metastases, the decalcification process makes the material unsuitable for gene sequencing. In this clinical setting, the results from molecular profiling would assist in making a rational decision on the next treatment regimen. Therefore, the Guardant360 biopsy-free tumor sequencing test was likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the Guardant360 biopsy-free tumor sequencing test at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in internal medicine with sub-specialty certifications in medical oncology and hematology and are actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certification in medical oncology 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: Medical Necessity
Decision: Upheld

A 45-year-old female enrollee has requested for continued acute psychiatric hospitalization for treatment of her bipolar disorder, type I. Findings:  The physician reviewer found that the patient has had no suicidal ideation. The medical records noted that the patients affect was brighter. Based upon the patients affective improvement, partial hospitalization level of care for the purpose of completing the patients index course of ECT is medically necessary.  Continued acute psychiatric hospitalization for the purpose of restarting the patients psychiatric medications and stabilizing the patient is no longer medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested residential behavioral health treatment services for the treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was cooperative and actively participated in all aspects of his treatment program.  He became more positive in his outlook, his mood stabilized, and he was getting along with his parents.  He had improved and no longer required the structured setting of a 24-hour residential center.  His living environment would not have undermined ongoing treatment at a lower level of care.  His parents were supportive and actively involved in treatment.  The current medical evidence does not support the services at issue in this clinical setting.  All told, residential behavioral health treatment services at issue were not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 20-year-old female enrollee requested cognitive behavioral therapy for medical treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  This patient has a significant formal thought disorder with debilitating symptoms and impairment across multiple domains of functioning.  She has been refractory to multiple somatic interventions.  However, during her recent hospitalization she was transitioned to clozapine.  As her admission progressed, the patient demonstrated several foci that may respond well to cognitive behavioral therapy.  Cognitive behavioral therapy has a proven track record in the treatment of mood disorders and anxiety.  However, it is also potentially useful for those with formal thought disorders, and recommended by trusted reference texts and supported by the peer-reviewed literature for these conditions.  All told, cognitive behavioral therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the neck surgery (C3-4 arthroplasty and C6-7 revision arthroplasty). Current medical literature supports the use of artificial disc adjacent to a fusion as having excellent outcomes that are superior to additional fusion. Hao and colleagues report that the clinical outcome of revision of cervical adjacent segment disease by artificial cervical disc replacement is satisfactory. The authors further noted that the risk of intervertebral disc degeneration in adjacent segments is significantly lower than that of artificial cervical disc fusion due to the presence of certain motor function postoperatively. Park and colleagues also found that in a small case series, revision surgeries provided successful outcomes in failed artificial disc replacement of cervical spine without major complications. Reinas and colleagues note that multilevel cervical disc arthroplasty provided good clinical and radiological outcomes, preserving global and segmental cervical mobility, while having a beneficial effect on sagittal balance. The authors further noted that these results held for two to four levels, making this technique a valuable option in selected patients with cervical multilevel cervical disc disease. Given that current medical literature supports the use of an artificial disc and improved outcomes from multilevel artificial disc specifically in the setting of a prior fusion, the service at issue was medically indicated. Therefore, the neck surgery (C3-4 arthroplasty and C6-7 revision arthroplasty) was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was 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: Overturned

A 57-year-old female enrollee has requested for acute mental health hospitalization services for treatment of her bipolar disorder. Findings:  The physician reviewer found that this patient had recently made a very serious suicide attempt. She was in no condition to be treated in a lesser level of care than in an acute hospital setting. It would not have been safe to discharge this patient.