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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Combivent Respimat.  Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for the requested medication has not been established. There are numerous formulary bronchodilators available to the patient. There is no documentation that the requested Combivent Respimat (ipratropium bromide and albuterol) is superior to the formulary bronchodilators available to the patient. Ipratropium and albuterol are both available separately as are other bronchodilators. The patient is already taking a long-term adrenergic bronchodilator, in Salmeterol Advair Diskus. In addition, there is a risk of bronchodilator overdose that with increasing doses does not provide any further bronchodilation but may cause tachycardia. Accordingly, Combivent Respimat is not medically for treatment of the patients medical condition. 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 internal medicine with sub-specialty certification in pulmonary disease 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 authorization and coverage for a replacement power wheelchair. Findings:  The physician reviewer found that Mukherjee and Pasulka state that pressure injuries frequently complicate the care of patients with spina bifida, particularly patients who use wheelchairs. Pressure injuries can occur due to many etiological factors, including cognitive/behavioral impairment (e.g., inability to comply with a pressure relieving schedule), sensory loss, nutritional deficits and hygiene issues (e.g., sweating or chronic urinary incontinence). Pressure injuries can occur no matter what type of power wheelchair or seating/cushioning system is used if an appropriate pressure relieving schedule is not in implementation and if the other underlying etiological causes of the pressure injuries are not identified and addressed. In this case, the patient has a history of multiple conditions, including hydrocephalus, developmental delay, spina bifida and spinal deformities. She has impairments and mobility deficits that are well-associated with these conditions. The patient has been using a power wheelchair to address her mobility issues but has developed pressure injuries. Given that the patient in this case has persistently sustained pressure injuries despite modifications to her current power wheelchair, it is not evident that the patient is performing appropriate pressure relieving maneuvers. A replacement of her wheelchair would not be expected to result in any change in her risk for pressure injuries. Therefore, the replacement power wheelchair is not medically necessary for treatment for the patients medical condition.Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested methadone for treatment of her chronic pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The patient has displayed aberrant behavior with opioid medications, including the use of THC.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  If there is any indication of aberrant behavior, then opioids should be weaned off or discontinued.  The current medical evidence does not support the requested medication in this setting.  Baron and colleagues reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  High-dose opiates may also cause adverse outcomes.  Ballantyne and Mao noted that prolonged use of high-dose opiates might induce abnormal pain sensitivity and tolerance.  All told, methadone is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old female enrollee has requested a neurology visit  for treatment of her intermittent numbness and tingling in the legs, subjective weakness in both lower extremities and blurred vision. Findings: The physician reviewer found that an extensive differential diagnosis has been considered by neurology, with a plan for clinical follow-up. The medical records show that the patient has had subjective neurologic symptoms in the absence of significant physical findings. Extensive diagnostic testing has been largely normal. There is no data submitted to indicate that the patient has an evolving neurologic condition. When last seen by a neurologist, she was partly improved. Her examination was largely normal, except for brisk left Achilles reflex. In this patients case, a follow-up neurology visit is not medically indicated.  Follow-up with the patients primary care physician is appropriate at this time.  All told, the submitted medical documentation does not establish the medical necessity of the requested service.
Appeal type: Medical Necessity
Decision: Overturned

A 22-year-old female enrollee has requested residential treatment services for the treatment of her eating disorder. Findings:  The physician reviewer found that this patient is a seriously ill woman with a multitude of psychiatric issues. Her progress in the RTF was not rapid, but she was improving somewhat. Her medications were being adjusted as needed and they appeared to be of benefit. Relatively continuous monitoring of the patients behavior seems to have been indicated during the period at issue. The patient also experienced side effects from her anti-psychotic treatment compromising its utility. She was still significantly ill with a need for treatment at the RTF level of care and this need extended. The fact that she was re-admitted shortly after discharge seems to strengthen this point.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for modifications to the existing power wheelchair including HCPCS Code E1007  power seat tilt and recline; HCPCS Code E2311  electronic seat; HCPCS Code E1012  power foot platform; HCPCS Code E2313  harness upgrade; HCPCS Code E2376  expandable controller with joystick. Ehlers-Danlos hypermobility syndrome is characterized primarily by joint hypermobility, chronic pain, and fatigue. In addition to pain related to mechanical factors at the affected joints, a generalized hyperalgesia has been described. This hyperalgesia may be due to a sensitized central nervous system, which suggests an underlying pain mechanism similar to fibromyalgia. Ehlers-Danlos hypermobility syndrome can have significant to profound impacts on overall function, including mobility. In a meta-analysis, pain, fatigue and psychosocial distress were also shown to have a significant impact on disability. Rehabilitation aims to reduce disability in order to improve quality of life, but the evidence related to the effectiveness of specific treatments for reducing disability is limited. The records provided for review document a history of Ehlers-Danlos hypermobility syndrome and chronic low back pain relieved by positional changes. The patient is reportedly independent with these positional changes. However, there is a lack of documentation to support an indication for the requested modifications to his existing power wheelchair. The requested power seat tilt and recline, electronic seat, power foot platform, harness upgrade, and expandable controller with joystick are not supported since the patient has sufficient capacity to effectuate pressure relief. All told, the requested modifications to the existing power wheelchair including HCPCS Code E1007  power seat tilt and recline; HCPCS Code E2311  electronic seat; HCPCS Code E1012  power foot platform; HCPCS Code E2313  harness upgrade; HCPCS Code E2376  expandable controller with joystick are not medically necessary for treatment of this patient to perform one or more mobility related activity of daily living or instrumental activity of daily living in or out of the home, including access to the community. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Intensive outpatient program (IOP) services.  The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Based on the records provided for review, this patient was at minimal risk of harm (score 1) due to a lack of current suicidal ideation and no self-harming behaviors. The patient denied any suicidal or homicidal ideation. He did not have any auditory or visual hallucinations or psychosis. The patient presented with some functional issues (score 2) due to some problems with comorbidities affecting his progress. There was no report of this patient requiring assistance with performing activities of daily living. The patients diagnoses included no medical condition that required the IOP level of care (score 1). The patients recovery environment was mildly stressful (score 1) due to a stable living situation. The records suggest the patients recovery environment was also supportive (score 1) due to family support and availability of treatment resources but also some difficulty in relationships with her family members. With regard to treatment and recovery history, the patient demonstrated recent success at the IOP program level of care (score 3) following prior treatment at the residential treatment level of care. The patient was cooperative with care while being involved in his treatment (score 1). The provider documented that the patient participated in his treatment plan and attended 12-step groups. The patient demonstrated insight into his need for treatment and treatment needs. Thus, the patient has a composite score of 10, which correlates with treatment in a community-based outpatient clinic setting. Thus, the patient was a candidate for treatment in a less restrictive than IOP level of care during the period under review. All told, the IOP services were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry 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: An enrollee has requested authorization and coverage for an abdominal panniculectomy. Findings: The submitted documentation supports the medical necessity of the requested services. The records document evidence of an overlapping, symptomatic lower abdominal pannus. She has well-documented functional impairment with chronic rashes, consistent with chronic fungal infections, as well as lower back pain. She has attempted conservative management with topical dermatologic treatment. The medical evidence supports the requested services in this clinical setting. Thus, the requested abdominal panniculectomy is medically necessary for the treatment of this patient.In this patients case, the lower overhanging abdominal pannus is considered an abnormal structure of the body. This overlapping lower abdominal pannus is a result of her treatment of obesity, which is considered a disease. The requested surgery will both improve function and create a normal appearance to the extent possible. Based on the examination and the available photographs, more than a minimal improvement in appearance is expected with the requested services. Therefore, the requested abdominal panniculectomy is reconstructive in nature. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in plastic 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 female enrollee requested a bone growth stimulator for medical treatment of her medical condition.  Findings:  Three physician reviewers found this patient underwent surgery for a non-union.  However, prior to application of a bone growth stimulator, there should be documentation of serial x-rays in the postoperative timeframe, demonstrative of a nonunion.  Generally, concerns for nonunion would not usually be raised until at least six weeks postoperatively, and standards would require serial imaging demonstrating a lack of healing.  In this patients case, the bone growth stimulator was applied immediately after surgery and there was no radiographic evidence of failed union postoperatively.  Thus, the requested bone growth stimulator is not likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Percocet for treatment of his chronic pain.  Findings:  The physician reviewer found that the submitted records do not indicate that all non-opioid treatment options have been utilized.  Behavior therapy has been discussed, but has not been completed despite much research to support its use. The records indicate that tolerance has taken place since the start of narcotics. Dose escalation is not a long term plan but a short term plan for the treatment of tolerance. When the dosage of opioids is increased, studies have shown that patients opioid tolerance level also increases and will take much longer to wean off.  In this patients case, it is clinically reasonable to consider alternatives to opioids. It should also be noted that opioids are not recommended treatments for sleep issues. Finally, the medical records indicate that a plan is in place to possibly treat and diagnosis his lower back pain without the need for oral medications. For all these reasons, Percocet is not medically necessary for the treatment of the patients medical condition. 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 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: Overturned

A 30-year-old male enrollee has requested authorization and coverage for Lyrica 300mg for treatment of the enrollees upper extremity pain, secondary to neck pain.  Findings:  The physician reviewer found that Lyrica is supported in the peer-reviewed literature as a safe and effective treatment for radiculitis and chronic pain due to spinal pathology. A multi-center trial demonstrated that patients being treated with Lyrica reported significantly lower mean pain scores than those being treated with placebo (Jeffrey). The study by Durkin, et al. indicated that pregabalin (Lyrica) is a safe and effective medication that may decrease perioperative opioid use in patients with more acute neuropathic pain than acute inflammatory pain and may also decrease the incidence of chronic pain. A randomized controlled study assessing patient outcomes following lumbar discectomy and administration of perioperative Lyrica found that perioperative administration of the drug is associated with less pain intensity and improved functional outcomes three months after lumbar discectomy (Burke, et al.). Therefore, Lyrica is medically necessary for treatment of the patients medical condition. The patient has tried and failed to benefit from standard therapy. Additionally, the patients medical condition is both chronic and seriously debilitating.  Therefore, the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for denosumab (Prolia) injections for treatment of the enrollees osteoporosis. Findings:  The physician reviewer found that Prolia is approved by the U.S. Food and Drug Administration (FDA) for the treatment of osteoporosis in postmenopausal women at high risk of fracture. Prolia has been shown to reduce the incidence of vertebral fractures by about 68%, hip fractures by about 40%, and non-vertebral fractures by about 20% over three years. Prolia is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture, defined as a history of osteoporotic fracture, or multiple risk factors for fracture, or patients who have failed or are intolerant to other available osteoporosis therapy. In postmenopausal women with osteoporosis, Prolia reduces the incidence of vertebral, non-vertebral, and hip fractures. In this case, the patient has severe osteoporosis and treatment is necessary. Evista has helped maintain the bone mineral density (BMD) in the spine stable, but the BMD of the patients hips has worsened. The patient requires a therapy that will target both vertebral and hip bone density. Reclast and Prolia are similarly effective in preventing fractures of spine and hip. However, this patient is noted to have experienced side effects with oral bisphosphonate. Thus, the likelihood that she will have the same reaction to a medication in the same class is high. It is a contraindication to expose the patient to another bisphosphonate and take a risk of causing another reaction. Requiring the patient to take Reclast is not appropriate and is contraindicated. Thus, treatment with Prolia is medically necessary for the management of this patients severe osteoporosis. 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 endocrinology, diabetes and metabolism 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 an L4-5 laminectomy/discectomy/decompression for treatment of his medical condition.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The medical records document multilevel degenerative disc disease.  The patient is status post left-sided L4-5 hemi-laminectomy and discectomy and now has recurrent low back pain.  There is a lack of support for the requested services in this clinical setting.  The MRI in this case does not support the presence of a recurrent herniation.  Although the provider uses that term, the radiologist noted epidural scarring and not recurrent herniation.  The medical records do not include documentation of a recurrent L5 nerve root radiculopathy, either sensory or motor.  A repeat surgery would be most likely to relieve symptoms if a recurrent herniation were present or when there is documentation of radiculopathy. This patients MRI documents multilevel possible pain generators including those at thoracic level and lumbar levels with involvement of not only intervertebral disc but facet joint structures.  All told, the requested L4-5 laminectomy/discectomy/decompression is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  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.