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

A 47-year-old male enrollee has requested acute inpatient substance abuse rehabilitation services for treatment of his behavioral health problems. Findings:  The physician reviewer found that the patient did not meet established criteria for admission to an acute inpatient substance abuse rehabilitation program. He was not suicidal, psychotic, homicidal or suffering from serious withdrawal symptoms at the time of admission or during his inpatient stay. He did not require 24-hour monitoring for behaviors considered to be life-threatening or a danger to self/others or for monitoring of medication effects. The patient could have been managed and treated at a less intense, less acute, level of care on an outpatient basis. A partial hospitalization program or an intensive outpatient treatment program in addition to community-based resources such as a 12-step program would have been medically appropriate in lieu of the acute inpatient hospitalization.
Appeal type: Experimental/Investigational
Decision: Upheld

A 48-year-old female enrollee has requested Xolair for treatment of her chronic urticaria. Findings:  Three physician reviewers found that the FDA-approved indication for Xolair is moderate to severe, persistent asthma in patients who have a positive skin test or invitro reactivity to a perennial aeroallergen, symptoms that are inadequately controlled with inhaled corticosteroids and a pre-treatment total IgE level of 30 or greater. Omalizumab is not medically indicated for this patient in accordance with these guidelines. There are no records of persistent asthma or laboratory confirmation of perennial aeroallergen symptoms or reversible airway disease. Coverage for Xolair is being requested for off-label treatment of the patients urticaria. Although there are published case reports of its use for the treatment of IgE-related urticaria and there have been positive results for this patient, its use remains experimental for this diagnosis. Further clinical trials are necessary for evaluation of omalizumab in the treatment of urticaria and the therapy cannot be supported at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female has requested coverage for a hospital bed utilized for one month for treatment of her post-surgical recovery.  Findings:  The physician reviewer found that abdominal wall strength and function is significantly compromised in the early aftermath following TRAM flap surgery, particularly in the setting of bilateral TRAM flap surgeries (Atisha, et al.). This can affect activities such as standing up straight and changing positions. Difficulties in basic mobility may be seen for days to several weeks or longer after surgery (Spector, et al.). By eight weeks postoperatively, however, there is typically a return to near baseline functional status (Dell, et al.). In the present case, the patient had difficulty in mobility after her bilateral TRAM flap surgeries. She was unable to get up her stairs to her regular bed. There are no indications in the records, however, that the patients needs could not have been met with a standard non-electric bed placed on her ground floor, set up with bed wedge(s) and possibly simple temporary side bed rails to help with transfers into and out of bed. The records do not establish that the patient had mobility impairments that necessitated a semi-electric hospital bed at home during her convalescence following her bilateral mastectomies and TRAM flap surgeries. In the absence of such evidence, the medical necessity of a hospital bed has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested residential treatment center level of care for the treatment of her behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the service at issue.  The patients developmental task of identity consolidation has been hampered by chronic anxiety and affective dysregulation exacerbated by interpersonal struggles and family discord.  Her psychiatric comorbidity and illness burden negatively impacted multiple domains of functionality.  Despite being treated previously in the outpatient, partial and acute levels of care, which included school-based services, psychotherapy and complex pharmacotherapy, the patient had not consolidated significant treatment gains.  Based on the medical documentation and clinical status at the time, safe and effective care could not have been adequately delivered in a less restrictive setting.  The record reflects that the patient was passively suicidal, anxious and hopeless. However, she was motivated to engage in therapy. Thereafter, the record describes systematic exposure therapy in addition to the other modalities afforded by the clinical setting.  The residential treatment provided has been reasonably expected to improve her condition and prevent a more serious episode of illness. Accordingly, residential treatment center level of care was and is medically indicated for the treatment of this patient.  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: Experimental/Investigational
Decision: Upheld

A 63-year-old male enrollee has requested ultrasonographic measurements of carotid intimal medial thickness (CIMT) for evaluation of his hypertension and risk for heart disease. Findings:  Three physician reviewers found that the American Society of Echocardiography (ASE) has published guidance for the performance of CIMT. In this particular case, none of the indications supported by the ASE for this diagnostic procedure are present. The decision to initiate therapy for dyslipidemia had already been made as the patient was either taking or advised to start taking medications prior to the CIMT study. The notes do not indicate that the prescribing provider used the information from the CIMT to alter decision making regarding the patients pharmacologic therapy. In the absence of more complete data regarding this patients risk, the study at issue was not likely to have altered this patients treatment strategy and therefore is investigational in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Adzenys XR-ODT. Findings:  The physician reviewer found that although Adzenys XR-ODT has not been demonstrated to be more effective than Adderall XR, this patients records document that Adzenys XR-ODT provides a better method of administering the medication that the patient can tolerate. The patients parent states that attempts to open the Adderall XR medication and sprinkle the Adderall XR contents in water or food was unsuccessful and that the patient was unable to tolerate this. The patient has attempted many alternative ways to administer the ADHD methods through capsules, sprinkles, tablets, and liquid form, but the patient has not been able to tolerate any of these administration methods. It does appear that the oral dissolvable tablets would benefit the patient as he has failed all other methods to properly ingest his ADHD medication. Therefore, the requested Adzenys XR-ODT is medically necessary for treatment of this patients medical condition. 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 psychiatry with expertise in child and adolescent 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: Experimental/Investigational
Decision: Upheld

A 34-year-old male enrollee has requested for NeuroStar Transcranial Magnetic Stimulation Therapy for treatment of his major depressive disorder.  Findings:  Three physician reviewers found that there are insufficient data on the use of TMS in patients with major depression to support the utility and safety of the treatment, especially with regard to the long-term (greater than two years), outcomes including safety and efficacy. The scientific data available on TMS thus far does not suggest that it would be superior in a patient with medication resistant depression. In addition, the records do not indicate that the patient has exhausted all standard treatment modalities proven in the clinical literature.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a lightweight wheelchair. The patients primary means of mobility is reported to be his power wheelchair. The patient should have a device that is reliable to provide his mobility needs on a daily basis.  In the event that the patients power wheelchair becomes non-operational, an equivalent, loaner power wheelchair should be provided by the durable medical equipment vendor until the primary wheelchair is fixed. If the patients power wheelchair is frequently non-operational (i.e., defective), it should be replaced by the durable medical equipment vendor with a new device that works reliably. If non-operational power wheelchairs are a consistent problem, a different vendor should be considered. A back-up manual wheelchair in anticipation of potential mechanical failure of the patients primary power wheelchair is not medically indicated. Therefore, the requested lightweight wheelchair is not medically necessary for the treatment of this patient. 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: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for custom foot orthotics. After careful review of the enclosed information and the pertinent guidelines and medical literature, the requested custom foot orthotics for this patient are medically necessary. The patients physical evaluation during the medical visit documented significant biomechanical changes to his feet. Specifically, the patient is noted to have a rear foot valgus, compensating forefoot varus, and a hypermobile first ray, which all lead to painful contracted second toes bilaterally. The provider recommended that the patient be fitted with custom foot orthotics to hold his feet in a proper biomechanical position allowing for reduction of foot pain. Custom foot orthotics will also defer further improper pull of muscles and tendons leading to a more significant hammertoe. Therefore, the requested custom foot orthotics are medically necessary for this patient.Final Result: The reviewer determined that the requested equipment 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 podiatry 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 68-year-old female enrollee requested radiofrequency neurolysis (CPT 64635 and 64636) for medical treatment of her sacroiliac joint pain.  Findings:  Three physician reviewers found that the requested services are not likely to be more effective for this patient than other available options. There is a paucity of adequate medical literature demonstrating the efficacy of radiofrequency ablation procedures for sacroiliac joint-mediated pain (Rupert, et al; Aydin SM, et al., 2010; Hansen, et al). Moreover, the patient had one day of relief following her previous sacroiliac joint injection, and it is not clear that this was a definitive clinical response beyond a placebo effect. Based on the documentation submitted for review and the medial literature cited, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret 100-40 mg, three tablets daily for eight weeks. Findings:  The physician reviewer found that according to 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 should be treated, except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1a patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 mg, three tablets daily for eight weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cranioplasty.Following decompressive hemicraniectomy, a cranioplasty is an indicated, standard of care surgical procedure performed to re-establish cranial protection of the brain, restore cranial cosmesis, improve cerebrospinal fluid (CSF) dynamics, and to avoid or correct conditions like the syndrome of the trephined. Extensive research has been performed to understand the timing of cranioplasty and the potential risks and benefits of early versus late cranioplasty. Some data suggests that early cranioplasty (i.e., within 3 months) may be associated with improved neurological recovery, although it may be associated with increased complications.In this case, the patients medical condition is an acquired large skull defect that is the result of a life-saving hemicraniectomy performed in the setting of an apparent large right middle cerebral artery stroke. The patient has survived, and there is no indication in the submitted documentation that the patient has an extremely short life expectancy (i.e., days to weeks). Cranioplasty is a medically necessary surgical procedure in a patient with anything other than a very brief life expectancy. The timing and nature of said procedure is left to the neurosurgeon performing it based on optimization of the patients medical comorbidities, the status of the incision and the underlying brain tissue, the presence or absence of hydrocephalus, the availability of the patients own cranial bone or the need for a prosthesis. Accordingly, the requested cranioplasty is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurological 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for total knee replacement of the left knee.The current medical evidence supports the requested service in this clinical setting. According to Price and colleagues, knee replacement surgery is one of the most commonly performed musculoskeletal surgical procedures. The surgical indications include osteoarthritis with knee pain, reduced function, and reduced quality of life. In this case, this patient already has a total knee replacement on the contralateral side and is satisfied with the outcome. Imaging studies have revealed osteoarthritis in the patients left knee, and the patient reports a loss of function. The patient needs the procedure to enhance his quality of life. Additionally, there is no contraindication to this surgery. Therefore, the requested total knee replacement of the left knee is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 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: A patient has requested authorization and coverage for thoracic facet joint injection and transforaminal lumbar epidural steroid injection. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees thoracic and lower back pain. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The current medical evidence does not recommend facet joint injections in the thoracic spine, as there is limited research on therapeutic blocks or neurotomies in this region.  Per the medical evidence, therapeutic epidural steroid injections are recommended as a possible option for short-term treatment of radicular pain with use in conjunction with active rehabilitation efforts. This patient presents with a history of chronic thoracic spine pain and chronic low back and left radicular leg pain following a motor vehicle accident in 2007. She reports worsening thoracic pain over the past two  years. Clinical examination findings did not document thoracic spine findings of facet mediated pain. There is imaging evidence of slight scoliosis convex to the right, with no discussion of facet joint pathology. She complains of low back pain with radiating burning pain to both legs to the calves with occasional numbness to the feet with compensatory muscle spasms. Clinical examination findings have not evidenced a focal neurologic deficit correlated with reported imaging evidence of L4/5 and L5/S1 mild bilateral neural foraminal narrowing and 2 mm annular bulge/tear at L5/S1. Relative to the thoracic facet injections, there is no clear indication to support the medical necessity of thoracic facet injections at this time. Relative to the lumbar epidural injection, there are no physical examination findings correlated with imaging evidence of nerve root compression and consistent with radiculopathy to support the medical necessity of lumbar epidural injections at this time. Therefore, the requested thoracic facet joint injection and transforaminal lumbar epidural steroid injection are not medically necessary 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.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old male enrollee has requested overnight polysomnogram (sleep test) for evaluation of his obstructive sleep apnea. Findings:  The physician reviewer found the submitted documentation and relevant literature demonstrates the medical necessity of the services at issue. Based upon the documentation provided, the patient has a diagnosis of sleep apnea which was not adequately treated with previous surgical intervention. As a result, the patient had been using a dental appliance. However, the patient had residual sleepiness. Thus, a follow-up sleep study was clinically indicated to assess the adequacy of dental appliance. It was medically necessary to have the study performed in a lab setting as the patient would be monitored and allowed for adjustments to be made to the dental appliance, if needed, during the study. Thus, the services at issue were medically necessary in this clinical setting. Based on the medical literature cited above and the documentation submitted for review, the services at issue were medically necessary for evaluation of the patients medical condition.