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

A 63-year-old male enrollee has requested authorization and coverage for oxycodone for treatment of the enrollees pain management.  Findings:  The physician reviewer found that based on review of the available records, the patient does have chronic pain in the low back and more acute pain in the cervical spine and the upper extremities. He has been on methadone, which is a very potent narcotic analgesic that stimulates multiple narcotic receptors along with the NMDA antagonism that has been implicated in the control of central pain syndromes and neuropathic pain. The patient in this case is a chronic pain patient who should be on a long acting medication with a breakthrough short acting medication that is available one to two times per day. The individual narcotic needs to be approved based on tolerance, receptor activity and side effects as well as addiction potential. There is data to suggest that the rotation of opioids is reasonable. However, methadone is a difficult medication to convert from as it has such a long half life and agonizes and antagonizes multiple receptors, so it is a difficult and delicate conversion. There is no reason the patient needs to be placed on oxycodone if the provider determines this is not the ideal choice for his medication. There are several new long acting and short acting medications that may be of benefit, including Butrans, Exalgo, Opana, and long acting oxycodone. All told, the records do not establish that the specifically requested narcotic compound is superior in this clinical setting. The patient should have a full pain evaluation with an opioid risk assessment to best determine the best medication option. Therefore, the requested medication has not been demonstrated to be medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee has requested a power wheelchair (group 2) for treatment of his chronic obstructive pulmonary disease.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment in this patients case.  The current medical evidence does not support the requested power wheelchair in this clinical setting.  Specific criteria must be met in order to establish the medical necessity of a power wheelchair.  These criteria include the demonstration that a power wheelchair is needed to perform in home mobility-related activities of daily living.  In this patients case, the records noted that he is ambulatory within the home environment.  Physical therapy assessments concluded that the patient is capable of ambulating with a rolling walker with a seat.  All told, the requested power wheelchair is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old female enrollee has requested Protonix, 40 mg. for treatment of her gastroesophageal reflux disease (GERD).  Findings:  The physician reviewer found that although the physiological mechanism is unclear, patients can experience a differential response to different proton pump inhibitor (PPI) preparations. This patient has a significant improvement while on the brand name version of Protonix when compared to the generic product. Given that the patient has tried and failed a 2-week course of the generic version of Protonix (pantoprazole) and her documented long-history of positive results with the brand name version, it is clinically reasonable for this patient to be treated with the superior medication. As such, the medical necessity of the requested Protonix has been established for the management of this patients GERD.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral Euflexxa injections for treatment of the enrollee who has a history of bilateral knee pain and torn meniscus of the left knee. Findings: The physician reviewer found that Johal and colleagues concluded that there is a general lack of reliable evidence that any specific brand is superior to others. Nationally recognized evidence based medical guidelines state that hyaluronic acid injections in the knee are recommended as a possible option for patients with osteoarthritis of the knee who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. Guidelines support hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. If there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to do another series. The medical literature has noted that there are no maximum amount of injections established by high quality scientific evidence, nor is one type of viscosupplementation supported over another. This patient presents with a long history of bilateral knee pain and has been diagnosed with osteoarthritis. The patient had failed previous conservative treatment with anti-inflammatory medications, analgesic medications, corticosteroid injection, and Synvisc injections. Since 2008, the patient had received good improvement in pain and function with the use of Euflexxa injections for the bilateral knees for six months at a time. Evidence based medical guidelines support repeat viscosupplementation injections for patients with osteoarthritis with documented significant improvement in symptoms for six months of more. There is a general lack of reliable medical evidence that any specific brand is superior to others. Given the patients response to prior Synvisc and Euflexxa injections, the continued use of Euflexxa injections is medically indicated. Therefore, Euflexxa injections are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage, and reimbursement, for physical therapy services. The enrollee has a history of hip pain and meralgia paresthetica. She injured her back about two years prior. The records report the enrollee has horrible groin pain, which causes difficulty with driving, sitting, standing for long periods, bending forward and an inability to lift anything greater than five pounds. A physical therapy progress note reports the enrollee would benefit from aquatic and physical therapy for pain relief and range of motion and strength improvements so that she can return to her normal activities. The enrollee reports she is currently on disability for this injury and cannot sit or stand for any significant length of time due to nerve pain. The physical therapy treatment notes provide insufficient objective clinical information to support the medical necessity for the dates of service under review as well as the requested additional hands-on physical therapy.  The clinical records do not establish the medical necessity of continuing a structured outpatient physical therapy treatment program.  After several months of treatment, the therapy notes do not provide evidence of objective impairment, such as motor strength, or lumbar range of motion, that has substantially improved to support the continuing necessity of physical therapy.Final Result: The reviewer determined that the requested services were not, and are not, medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested acute psychiatric inpatient services for treatment of her depression and eating disorder.  Findings:  The physician reviewer found that considering the robust affective, psychodynamic and characterological aspects of this patients condition, selection of the appropriate level of care and length of stay is challenging. Clinical guidelines and patient placement criteria have been developed to assist with such complicated determinations, and it is the task of the providers working directly with the patient to interpret and apply these tools. In this patients case, the documentation provided does not describe an acute psychiatric syndrome, significant disability, or medical illness that would necessitate services at the acute level of care. The patient was struggling with a formidable and enduring symptom complex that demanded comprehensive specialty care. However, she was not acutely suicidal, psychotic, or cognitively impaired. The patient had failed mental health treatments in the outpatient setting but had not pursued less restrictive subacute or residential care. Additionally, in reference to her eating disorder, she had an unremarkable physical examination. She had a normal heart rate and her electrocardiogram demonstrated normal sinus rhythm with a normal QTc interval. Although suggestive of menopause, her laboratory analysis was otherwise normal.  Although the patient had chronic underlying issues of significance including parasuicidality, ambivalence, self-defeating behaviors, characterological issues, mood symptoms and anxiety, and continued body distortionism, the patient was a candidate for treatment in a less restrictive environment and did not require the intensity and medical supervision provided at the acute level of care. All told, psychiatric services at the acute level of care provided from the time frame specified were not medically necessary for treatment of the patients medical conditions.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting reimbursement for intensive outpatient program (IOP) level of care. The enrollee entered an intensive outpatient program after one month in an inpatient program. She has diagnoses of post-traumatic stress disorder (PTSD) and depression and was on a medication regimen. At the time of admission to the IOP, she was not suicidal, but reported an involuntary psychiatric commitment in the past due to the possibility of her being a danger to herself or others. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The recommended level of care is level II, low intensity community based services. Medical evidence does not support the IOP level of care during this time period.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 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee has requested CT angiography (CTA for evaluation of his coronary artery disease (CAD). Findings:  Three physician reviewers found that CTA is still considered investigational in most applications and is not a substitute for cardiac catheterization or nuclear SPECT imaging. In addition, the technology is not fully supported by the AHA and a consensus statement in 2006 confirmed that the test is not ready for widespread use at the time. Inherent limitations include sensitivity and specificity, the need for a low heart rate, the lack of visualization of distal vessels, the use of potentially nephrotoxic dye and radiation exposure. While the noninvasive nature of CTA makes it an attractive test, its exact role in the diagnostic algorithm of coronary artery disease is not fully defined.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 31-year-old woman who had gastric bypass surgery approximately 18 months ago and has lost over 100 pounds.  She is bothered by redundant skin on her arms, breasts and abdomen. The patient has experienced neck and back pain in the past and was recently referred to a dermatologist for a rash under her breasts.  Her plastic surgeon requested authorization for a panniculectomy, which the Health Plan has denied.Based upon review of the medical records and the photographs provided, the proposed panniculectomy is a cosmetic procedure and does not satisfy the criteria for medical necessity.  Medical therapy for the rash under the patients breasts is ongoing and not related to the requested panniculectomy. The photographs of the patient do not support the premise that her back and neck pain are caused by the excess abdominal skin. As such, there is no evidence a panniculectomy is medically warranted in this case. Therefore, I have determined that the requested surgery 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 55-year-old female enrollee has requested Botox injections for treatment of her migraines. Findings:  Two physician reviewers found the submitted documentation and relevant literature fails to support the use of Botox injections in this clinical setting. Although Botox injections can be useful for some patients with migraine headaches, it does not work for all patients. In this case, the patient had a trial of Botox and was subsequently evaluated by her provider who documented that the patient did not have improvement with Botox. Thus, its continued use would likely not be more beneficial than other standard therapy. Therefore, the request for Botox injections is not likely to be more beneficial than other standard therapies.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 50-year-old male with multiple sclerosis. He reports being hot all the time and therefore wishes to utilize a cooling vest. The Health Plan has denied authorization for the requested device on the basis that it is not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. There is no evidence the requested post-surgical cooling device is medically appropriate for this indication. The use of a cooling device for the treatment of multiple sclerosis has not been validated in the peer-reviewed literature. As such, there is no data demonstrating that the requested device is likely to be beneficial for the patient. Accordingly, I have determined the requested device is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 36-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 29-year-old male enrollee has requested psychiatric acute inpatient services for treatment of his behavioral health conditions. Findings:  The physician reviewer found thatthe medical records document co-occurring substance dependence and a serious formal thought disorder, which as a class represents the most severe of psychiatric illnesses.  He has multiple risk factors for aggressive behavior and suicidality.  According to the medical records, the patient has made some improvement regarding affect, appetite and sleep during the hospitalization.  However, the most recent psychiatric assessments were notable for continued paranoia and poor insight.  The patient has history of suicide attempt, drug use and violent behavior with an enduring psychotic burden, and subsequent cognitive impairment due to his mental illness, with continued delinquency in maintaining his activities of daily living. In sum, the inpatient services in dispute are reasonably expected to improve the patients condition and prevent a more serious episode of illness.  All told, psychiatric acute inpatient services from the date indicated forward were and are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a bilateral lumbar medial branch block procedure. The patient has low back pain without radiation into the lower extremities. An MRI revealed disc bulges at L3-4 and L4-5 and mild bilateral facet arthrosis from L3-4 to L5-S1. The records suggest the bilateral lumbar medial branch block is for therapeutic purposes. A study found that the prevalence of high quality studies regarding the use of therapeutic medial branch blocks is limited. The best evidence for the use of medial branch blocks is for diagnostic purposes leading to a radiofrequency ablation procedure. Another study concludes that, facet blocks are not therapeutic. The records do not support that the injections are for diagnostic purposes, to help determine if the patient is a candidate for radiofrequency ablation, as supported in the medical literature. Therefore, the requested procedure 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 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

An 18-year-old male enrollee has requested adult mental health inpatient treatment for the treatment of his bipolar disorder and obsessive compulsive disorder. Findings:  The physician reviewer found that from the standpoint of the patients escalating volatility at home, clearly reenacted while he was on the unit, the approach to his treatment was well within community standards for treatment of Bipolar Disorder.  Review of the unit notes, inclusive of nursing staff and psychiatrist, point to his impulsivity, aggression, verbosity, and intrusion as flagrant problems, which did not sizably lessen until very close to the point of discharge.  In the context of how serious these problems are for the patient, both in and out of the hospital, placement is an integral part of his treatment plan. A few more days were appropriate in order to ensure the patient was stable and to allow for transition to a lower level of care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Synvisc (hyaluronan) injection series in the right knee.Findings: An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has had good benefit from viscosupplementation with Synvisc-One in the past, although Orthovisc did not provide relief. Furthermore, the options are limited, and the patient wants to postpone total knee arthroplasty. Therefore, the requested Synvisc (hyaluronan) injection series in the right knee is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 61-year-old male enrollee has requested Lyrica for the treatment of his peripheral neuropathy. Findings:  The physician reviewer found that the patients symptoms are attributable to nerve damage and he has been diagnosed with chronic neuropathic pain of the neck, upper thoracic spine and upper extremities. He has shown consistent response to Lyrica for the past 18 months. This medication is being used for its antineuropathic effects, which have been validated for conditions such as diabetic polyneuropathy and post herpetic neuralgia. Off-label use of Lyrica for other types of neuropathic pain is common within the Neurological and Pain Management communities. Lyrica is an appropriate treatment for this patient due to its profile of minimal side effects and broad efficacy in the management of neuropathic pain. Additionally, it would not be in the patients best interest to discontinue this particular drug considering his response.