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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Ocrevus and Norco (hydrocodone) for treatment of the enrollees multiple sclerosis (MS) and chronic pain. Findings:  The physician reviewer found that the request for Ocrevus is medically necessary for treatment of the patients medical condition. Ocrevus is U.S. Food and Drug Administration (FDA) approved for treatment of MS. Colleagues performed two phase-III randomized clinical trials that demonstrated superiority of ocrelizumab over interferon beta in relapsing-remitting MS (RRMS) patients with regards to clinical and paraclinical outcome parameters. The short-term adverse events profile is favorable. Colleagues found that among patients with relapsing multiple sclerosis, ocrelizumab was associated with lower rates of disease activity and progression than interferon beta-1a over a period of 96 weeks. In addition, although Ocrevus and Rituxan both target CD20-positive B cells, they are different molecules in their structure and how they interact with the immune system. These two drugs bind overlapping but different epitopes on the CD20 molecule. Ocrevus and Rituxan differ in how efficiently they target B-cells. Ocrevus has a higher capacity for direct, antibody-dependent, cell toxicity compared to Rituxan. The records indicate failure of Tecfidera. Given that Ocrevus has shown to be superior to Rituxan as well as being FDA approved for treatment of MS, Ocrevus is medically necessary. The request for (hydrocodone) Norco is not medically necessary for treatment of the patients medical condition. Hydrocodone is an opioid analgesic recommended for pain management when other conservative care has failed. The record notes that the patient has been referred to physical and occupational therapies, however there is no documentation showing the patient has participated in an adequate course of therapy. In addition, opioids are generally not recommended as first-line therapy but, when used, providers should closely monitor patients for loss of response, adverse effects or aberrant behavior, and revise the treatment plan accordingly. The records do not show the patients response to pain medication including the duration of symptomatic relief, functional improvements, and the level of pain relief with Norco. Congruent with the current peer-reviewed guidelines, the requested Norco is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that a portion of the requested medications is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in neurology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential sub-acute detoxification (HCPCS code H0010), residential treatment center services (HCPCS code H0018) and intensive outpatient services (HCPCS code H0015). Findings:  The physician reviewer found that The American Society of Addiction Medicine (ASAM) criteria is an accepted, national standard for determining the appropriate level of care for adults with substance use problems. With regards to acute intoxication and/or withdrawal potential, the patient had mild withdrawal symptoms at the time of admission. In terms of biomedical conditions and complications, the patient did not have any medical problems which required 24-hour monitoring. With regards to medical/addictive/psychiatric comorbidity, the patient does have a history of anxiety and depression. However, on admission, the patient did not endorse any anxiety or depression. In terms of readiness to change, the patient reported that she was motivated for change and wished to engage in treatment. With regards to relapse, continued use or continued problem potential, she had long periods of time with sobriety. The patient has been able to maintain abstinence with minimal support. In terms of recovery/living environment, the patient struggled with her marriage. Based on the ASAM criteria, the patient could have been treated in a less restrictive environment with outpatient services. She also could have engaged in 12-step programs. The medical evidence does not support the services at issue in this clinical setting. All told, residential sub-acute detoxification (HCPCS code H0010) provided, residential treatment center services (HCPCS code H0018) provided and intensive outpatient services (HCPCS code H0015) provided were not medically necessary 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: Upheld

A 57-year-old female enrollee has requested a power wheelchair for treatment of her chronic airway obstruction.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested equipment.  The records indicate that the patient has normal strength in the limbs and no range of motion deficits in the limbs that would preclude ambulation with the assistance of an assistive device such as a cane or walker with seat.  This patient has multiple chronic health conditions, such as chronic obstructive pulmonary disease with ongoing tobacco abuse, hypertension and diabetes, which would benefit from increased physical activity and exercise.  Regular use of a power mobility device would decrease her physical activity levels and would be expected to worsen her health conditions.  All told, the requested power wheelchair is not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested Lynparza for medical treatment of her breast cancer.  Findings:  The physician reviewer found that according to Lynparzas prescribing information, 2% of patients enrolled in olaparib monotherapy developed MDS or acute myeloid leukemia (AML). This case is particularly complex because the patient has MDS.  Olaparib is not recommended unless hematological toxicities of prior chemotherapy have resolved to less than grade 1, Common Terminology Criteria for Adverse Events (CTCAE) criteria. Furthermore, according to the label if MDS/AML are confirmed then olaparib is to be discontinued. In this patients case, olaparib could accelerate the MDS process to AML. Therefore, the request for Lynparza is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee has requested lap band surgery for treatment of her obesity.  Findings:  The physician reviewer found that this patient does meet the National Institutes of Health guidelines for weight loss surgery. The available scientific evidence does not indicate that delaying weight loss surgery will provide any benefit to this patient. Following psychological evaluation, no contraindications to surgery were noted. The patient has a BMI of 43.3.  She has significant comorbid conditions, including osteoarthritis, lumbago and pain in the knees, ankles and feet. The current medical evidence supports the requested lap band surgery in this clinical situation. Therefore, the requested procedure is 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 positron emission tomography (PET) scan. Findings:  The physician reviewer found that The records provided for review document that this patient was diagnosed with triple negative breast cancer in 2014 with recurrence in 2018. A PET scan showed activity in a left thyroid nodule measuring 1.4 cm stable compared to prior and possibly reactive right axillary lymph nodes. Bilateral breast MRI noted changes of mastectomy and subpectoral implant reconstruction without evidence of adenopathy and the imaged bones, intrathoracic soft tissues, and intraabdominal soft tissues were unremarkable. Based on the available records, there is no current indication for a PET scan. The National Comprehensive Cancer Network (NCCN) guidelines do not support routine use of PET scans for the surveillance of patients with triple negative breast cancer. Current data have reported that PET imaging has high false-negative rates in the detection of lesions that are smaller than 1 cm or are low grade. For these reasons, the requested PET scan is not medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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 57-year-old male enrollee has requested for osteopathic treatment for treatment of his patellofemoral syndrome. Findings:  The physician reviewer found that there is no justification for osteopathic treatment due to knee pain. Osteopathic manipulation has not been proven safe and effective in the long-term treatment of chronic patellofemoral pain.  The patient has also had hip pain.  There is insufficient support for the request for osteopathic treatment due to chronic complaints of pain with the diagnoses of patellofemoral syndrome and left hip degenerative joint disease.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a 16-year-old enrollee has requested reimbursement for residential treatment center services provided.Findings:  The physician reviewer found that the residential treatment center services provided were medically necessary for treatment of the patients medical condition. A study recommend that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports. In this case, the patient continued to have unsafe behaviors and discharge to a lower level of care on the disputed date would not have been safe or effective. The patient was struggling with suicidal and homicidal ideation. She engaged in serious self-harm behavior that included smashing her head against a wall. She continued to have suicidal ideation during the dates in dispute and reported on several occasions a plan to harm herself. The patient had a significant risk of harm due to her repetitive suicidal ideation as well as self-harm including head banging. Moreover, she had minimal insight into her treatment needs, displayed poor boundaries and inappropriate with peers. Based on the records submitted for review, the services at issue were medically necessary for treatment of the patients medical condition.Final Result: The reviewers determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer is  board certified in psychiatry with sub-specialty certification 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: Medical Necessity
Decision: Overturned

A 36-year-old male enrollee has requested reimbursement for a three-night home sleep study for evaluation of the enrollees sleep disturbance. Findings:  The physician reviewer found that the medical records provided indicate that the patient had a high pre-test likelihood of having sleep apnea. Therefore, the patients provider ordered a home sleep study. A home sleep study is a reliable test to evaluate patients for obstructive sleep apnea. However, the available peer-reviewed medical literature indicates that one night of a home sleep study is adequate for assessing patients for obstructive sleep apnea. There is no indication in the literature that additional nights are needed to accurately assess a patient for obstructive sleep apnea. All told, one night of the sleep study at issue was medically indicated and should be covered. The Health Plans denial should be partially overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Transurethral destruction of prostate tissue by radiofrequency generated water vapor thermotherapy (CPT 53854 and 0360). Radiofrequency generated water vapor thermotherapy with Rezum is a novel technique to treat male urinary symptoms secondary to benign prostatic hyperplasia (BPH) due to an enlarged prostate. McVary and colleagues reported that their sham-controlled trial showed improved storage and voiding symptoms after the thermal therapy procedure. Overall, current medical literature does not support improved efficacy of Rezum procedure over current standard of care consisting of transurethral resection of prostate (TURP). In addition, long-term outcomes of radiofrequency generated water vapor thermotherapy have not been established. Hence, although the Rezum procedure is a promising procedure for treatment of BPH, it is not considered standard of care for treatment of BPH refractory to medical therapy. For these reasons, the transurethral destruction of prostate tissue by radiofrequency generated water vapor thermotherapy (CPT 53854 and 0360) was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the transurethral destruction of prostate tissue by radiofrequency generated water vapor thermotherapy (CPT 53854 and 0360) was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in urology and are 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for hydroxyprogesterone 1 mg weekly injections for treatment of the enrollees pregnancy. Findings: The reviewer found that the weekly intramuscular progesterone has been shown to be effective in decreasing the risk of preterm birth in women who have a history of prior spontaneous preterm birth. This patient has not had a prior preterm birth. Although she had an episode of preterm contractions, progesterone has not been shown to be effective in significantly delaying delivery in patients with preterm labor that has been effectively treated with other medications. Accordingly, the requested hydroxyprogesterone 1 mg weekly injections are not supported as medically necessary for treatment of this 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 obstetrics and gynecology with sub-specialty certification in maternal and fetal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 26-year-old female enrollee requested reimbursement for residential treatment. The Health Plan denied the request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health problems.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee has requested inpatient hospital stay for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The current medical evidence does not support inpatient services in this clinical setting.  Inpatient care is necessary when the patients signs and symptoms and medical condition can only be managed safely in an acute inpatient setting or when the patient requires diagnostic studies in an inpatient setting.  In this case, the patient was admitted in stable condition and could have been treated at an observational level of care.  All told, an inpatient hospital stay was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested a total hysterectomy for treatment of her pelvic pain and abnormal uterine bleeding. Findings:  The physician reviewer found that the American College of Obstetrics and Gynecology Bulletin on anovulatory bleeding recommends an endocrine evaluation to assess for a correctable cause of the bleeding.   There does not appear to have been any workup other than the D&C.  These guidelines note that women who are older than 40 years of age and who have anovulatory uterine bleeding can be treated with low-dose oral contraceptives or cyclic hormone replacement therapy. They note that surgical therapy is indicated for women with excessive anovulatory bleeding in whom medical management has failed and who have completed their childbearing. There was no pathology noted on the patients laparoscopy that could explain her pelvic pain, and it may thus be that her pain symptoms are due to some other cause, such as a urinary or gastrointestinal etiology. There can be many causes of pelvic pain, and the submitted documentation does not include a detailed history or a comprehensive evaluation. All told, the submitted evidence does not demonstrate that the patient meets medical necessity indications for hysterectomy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an implantable cardioverter defibrillator. The submitted documentation supports the medical necessity of the requested service. The patient has been treated with carvedilol and losartan, standard medications for left ventricular dysfunction. The patients ejection fraction has not improved and a left bundle branch block electrocardiogram (EKG) pattern in present. The patient therefore meets standard criteria for prophylactic implantable cardioverter defibrillator implantation. Use of an implantable cardioverter defibrillator under these circumstances is consistent with American College of Cardiology (ACC) guidelines. Furthermore, the fact that the patient is undergoing chemotherapy and radiation, which may worsen her heart function, only strengthens the need for device implantation. Accordingly, an implantable cardioverter defibrillator is medically necessary for 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 internal medicine, with subspecialty certification in cardiovascular 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: Overturned

The parent of an eight-year-old male enrollee has requested  coverage for speech therapy at a frequency of 2 sessions per week for 30 minutes per session for treatment of his autism.  Findings:  The physician reviewer found that this eight-year-old autistic patient has a severe language delay. Speech therapy has been successful, but progress has been slow due to his inability to focus and concentrate, his cognitive impairments, and his tantrum behavior. While the patients progress has been slow, there is a large body of medical literature supporting speech therapy in autistic children.  As noted by Myers and colleagues, People with autism spectrum disorders (ASDs) have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services. In a controlled study comparing autistic children who did and did not receive speech therapy, it was noted that those who did receive therapy had far greater communication skills than children who did not receive speech therapy (Turner, et al.). The Speech and Language Association also states that all autistic children can benefit from speech therapy and emphasizes that age, either early or late in life, is not a barrier to speech therapy. Additionally, the common practice within the medical community would be to continue individual speech therapy for this patient. Therefore, the requested speech therapy at a frequency of 2 sessions per week for 30 minutes per session is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 36-year-old male enrollee has requested an increase in IVIG therapy for treatment of his multifocal motor neuropathy. Findings:  The physician reviewer found that IVIG has been shown to be effective in multiple placebo-controlled studies of multifocal motor neuropathy. The Cochrane collaboration has completed a meta-analysis, which confirms clinical efficacy.  The usual initial dose of IVIG is 2gm/kg to be given over one to five days. The Health Plans approval of one day of treatment per month at a dosage of .4gm/kg is inadequate and not supported by peer-reviewed literature.