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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for neuropsychological testing for evaluation of the enrollee, who has been diagnosed with attention deficit/hyperactivity disorder. Findings:  The physician reviewer found that there is sufficient support for the requested services in this patients case.  This patient has been diagnosed with attention deficit/hyperactivity disorder, but there is also concern for autism spectrum disorder because of his behaviors, pragmatic speech deficits, and lack of social skills.  It can be difficult to differentiate between these two neurologic disorders because of commonalities in clinical presentation.  Special training is essential to make the appropriate diagnosis because management of the two disorders can be quite different.  The impact of inaccurate diagnosis and management can have lifelong consequences. Given the extent of this patients neurologic challenges and uniqueness, neuropsychological testing is medically necessary and would be considered standard of care.  Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in pediatrics 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 PET/CT scan for an evaluation of her endometrial carcinoma. Findings:  The physician reviewer found that PET/CT scans are still investigational for endometrial cancer surveillance. At present, PET/CT has not been proven to be more effective than standard imaging studies in this setting. As such, the proposed PET/CT scan is not clinically indicated for this patient. The patients condition can be appropriately monitored through other measures.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old female enrollee has requested authorization and coverage for 240 tablets of hydrocodone 5/500 monthly for treatment of her low back pain.  Findings:  The physician reviewer found that the requested number of hydrocodone tablets does not meet generally accepted standards of medical care for treatment of non-specific chronic low back pain. The standard of care in cases such as this is to determine the etiology of the patients low back pain and then incorporate other pain medications (long-acting) in concert with physical rehabilitation and other modalities to help diminish the patients excessive use of hydrocodone.
Appeal type: Medical Necessity
Decision: Upheld

 The patient has requested authorization and coverage for skilled nursing facility (SNF) services. At the time of admission, the patient required skilled rehabilitation services to improve her function but she did not have any documented skilled nursing needs. The patient received skilled care and improved. Subsequently, the patient did not require any skilled nursing or rehabilitation services on a daily basis. She was not expected to make measurable gains within a reasonable and predictable timeframe and she did not require skilled therapy to prevent deterioration with mobility or activities of daily living. Moreover, the patient did not require skilled therapy to establish a safe and effective maintenance program. The patient did not have any parenteral medications, complex wound care or nutrition given via a feeding tube. Her function had plateaued and she did not require further inpatient skilled rehabilitation services. The physician reviewer found that  SNF services provided were not and are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 31-year-old woman who has extensive, severe psoriasis. She reportedly has had mildly elevated liver enzymes. The psoriasis has not responded to topical treatments. The patients dermatologist indicates that Soriatane is contraindicated in women of childbearing age. In addition, the patients dermatologist states that methotrexate is contraindicated in patients with abnormal liver enzymes and may cause hypertension. Furthermore, the patient indicates that the nearest ultraviolet treatment facility is inaccessible because of its distance from the patients home and work. The patients dermatologist has recommended Raptiva to treat the patients psoriasis. The Health Plan has denied the patients request indicating that the requested medication is not medically necessary.The Health Plans denial should be overturned. Raptiva appears to have a much more acceptable safety profile than methotrexate, Soriatane or cyclosporine. Furthermore, ultraviolet treatment is precluded in this case due to the distance of the nearest ultraviolet treatment facility. As far as pregnancy risk is concerned, cyclosporine, like Raptiva, is a category C medication. There is no evidence that Raptiva has a greater miscarriage or teratogenicity risk than cyclosporine. Furthermore, Soriatane and methotrexate are contraindicated in women who want to become pregnant. Thus, Raptiva appears to be a medically reasonable and appropriate alterative for this patient. Based upon the information set forth above, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for requested Euflexxa injections in both knees. The enrollee has bilateral knee osteoarthritis, left worse than right. Prior treatment with hyaluronic acid lasted about five to six months, with good improvement in her pain. The enrollee reported her pain had recurred over the past couple of months. She described it as aching and dull. She also noted minimal intermittent knee swelling. Given her lack of improvement with treatment modalities to date, the enrollee received a trial of viscosupplementation, with Orthovisc Injection #1 provided during the office visit. Intra-articular hyaluronic acid injections (Euflexxa) are standard practice for the treatment of mild-to-moderate knee arthritis. This enrollees history and response indicate she is a good candidate for the requested intra-articular hyaluronic acid injections (Euflexxa).Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 22-year-old male enrollee has requested authorization for IBD First Step testing for evaluation of his irritable bowel disease (IBD). Findings:  The physician reviewer found that the gold standard for determining the specific diagnosis for a patient with irritable bowel disease is colonoscopy and biopsy. The use of IBD testing is not the standard of care. Recent literature suggests that standard testing has a higher positive predictive value and is more sensitive and  more specific.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for wireless capsule endoscopy for evaluation of the enrollees follicular non-Hodgkins lymphoma of the intestine. Findings:  The physician reviewer found that according to the American Society for Gastrointestinal Endoscopy (ASGE), evaluation of small intestinal tumors is a valid indication for wireless capsule endoscopy. Wireless capsule endoscopy is capable of discovering small bowel tumors not visualized with endoscopy and traditional radiologic imaging. Wireless capsule endoscopy is a useful diagnostic tool for defining the extent of bowel involvement in patients with gastrointestinal lymphoma. Patients with primary intestinal follicular lymphoma should undergo endoscopic examinations, including wireless capsule endoscopy, to evaluate the entire gastrointestinal tract prior to consideration for potential treatment. For these reasons, wireless capsule endoscopy is supported as medically necessary for the evaluation of this patients intestinal follicular lymphoma. Final Result: The reviewer determined that the requested diagnostic procedure is medically necessary for evaluation 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

The parent of a two-year-old female has requested speech therapy, 30 minute sessions, twice per week for treatment of her mild to moderate receptive language impairment and severe expressive language impairment.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested therapy in this patients case.  As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability.  Per the authors, identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  According to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In this patients case, she demonstrates speech and language deficits which are most prominent in her expressive language skills.  These deficits are impacting her ability to communicate in a functional and age-appropriate manner.  Studies have shown that speech and language therapy can result in significant improvement in such children.
Appeal type: Medical Necessity
Decision: Upheld

The patients parent has requested reimbursement for neuropsychological testing. The American Academy of Pediatrics (AAP) report that the diagnosis of attention-deficit/hyperactivity disorder (ADHD) is made based on clinical history and interviews with patients and their caregivers, as well as collateral information obtained from teachers. Researchers found that neuropsychological testing has not been found to improve diagnostic accuracy in most cases, although it may have benefit in clarifying the child or adolescents learning strengths and weaknesses. In this case, the patient underwent neuropsychological testing at the recommendation of his school psychologist. The provider who performed the testing expressed concern that patients inattention, impulsivity, and anxiety might have affected the testing results. The records do not include documentation of a prior clinical assessment or treatment of the patients ADHD symptoms by a psychiatrist, psychologist, or pediatrician. Overall, the records do not support an indication for a full neuropsychological assessment, rather than a clinical assessment for ADHD. All told, the neuropsychological testing was not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 psychiatry with subspecialty 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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with osteoporosis. A bone mineral density test revealed an L1-4 spine T-score of -2.5, a right femur neck T-score of -2.8, and a left femur neck T-score of -2.9. The provider noted the patient had fractured her feet three times, and the last fracture occurred approximately 10 years prior.  The patient had been on Evista during the last 10 years and was on Fosamax for approximately 10 years before that. Physical examination findings were unremarkable. The patient has requested authorization and coverage for Prolia injections. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Prolia injections are medically necessary for the treatment of the patients medical condition. Researchers reported, Treatment is generally recommended in postmenopausal women who have a bone mineral density T score of -2.5 or less, a history of spine or hip fracture, or a Fracture Risk Assessment Tool (FRAX) score indicating increased fracture risk. Bisphosphonates (generic) and denosumab reduce the risk of hip, nonvertebral, and vertebral fractures. In this case, the patient has osteoporosis with a history of fragility fractures. Her prior treatment included Evista and Fosamax. Given her history, Prolia is a medically appropriate therapy. The current guidelines do not recommend one therapy over another, and there is no stepwise therapy. Prolia has been demonstrated to be an effective treatment for postmenopausal osteoporosis. Therefore, Prolia injections are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology 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: Overturned

A 54-year-old male enrollee has requested keratoprosthesis implantation for treatment of his visual impairment.  Findings: Two physician reviewers found that the requested keratoprosthesis implantation will improve the patients visual function and help to create a more normal appearance. The safety and effectiveness of the procedure is well established in the literature and this approach has been endorsed by the medical community. For this particular patient who cannot undergo keratoplasty using donor tissue, keratoprosthesis implantation is an appropriate alternative.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for a lymphocyte transformation test. Metal hypersensitivity is a possible cause for arthrofibrosis and associated pain in patients after joint arthroplasty. For this patient, the requested lymphocyte transformation test is appropriate because it will help guide treatment. Researchers found that lymphocyte transformation testing shows promise in diagnosing metal allergy and components of bone cement are also being recognized as potential allergens. Further, additional studies have reported some clinical utility in performing the test for patients who have clinical signs of potential metal hypersensitivity, such as this patient. The results of the lymphocyte transformation test will help establish whether the patient requires a revision arthroplasty with special metals that limit hypersensitivity. For these reasons, the requested lymphocyte transformation test is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery 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

A 54-year-old male enrollee has requested authorization and coverage for Lyrica. Reviewer's Finding:The reviewing physician found that while the FDA guidelines support the use of Lyrica for various neuropathic pain syndromes, this patients diagnosis is low back pain. There is no documentation suggesting the proposed treatment is consistent with the FDA-approved indications or the generally accepted off-label use of Lyrica for the treatment of neuropathic pain syndromes
Appeal type: Medical Necessity
Decision: Overturned

A 31-year-old male enrollee has requested re-treatment with Rituxan for treatment of rheumatoid arthritis.  Findings:  The physician reviewer found that Rituxan has received FDA approval for the treatment of rheumatoid arthritis. Its effectiveness has been repeatedly demonstrated in trials involving various regimens including steroids, methotrexate, and cyclophosphamide, as well as in patients who previously failed TNF inhibitors.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested partial hospitalization program (PHP) services for the treatment of her depression. Findings:  The physician reviewer found that the patient was not a major suicidal risk at the time of admission to the PHP. The admission note is silent as to what treatment, if any, the patient received from the time of acute hospital discharge until PHP admission. A note from the PHP purports that the patients mental illness constitutes a serious threat to health. Further, the provider states, patient is a significant safety risk thus necessitating her admission in our partial hospital program. The latter statement does not agree with the information contained in the PHP admission note. There is no record that the patient was treated in any way from the time of acute hospital discharge to the time of PHP admission. Her need for PHP treatment is not demonstrated. She could have been safely and effectively treated in a less restrictive program of care, such as an intensive outpatient program.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old male enrollee requested authorization and coverage of out-of-plan photodynamic therapy for the treatment of barret's esophagus with high and low grade dysplasia.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.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 for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Revlimid (lenalidomide) combined with dexamethasone and daratumumab to be administered over an initial six-month period and forward. Findings:  The physician reviewer found that the patient has smoldering multiple myeloma without calcium, renal failure, anemia, and bone lesion (CRAB) symptoms. Per the provider, prior treatment Revlimid in July 2020 resulted in transaminitis. The patients provider has recommended treatment with Revlimid with dexamethasone and daratumumab. However, daratumumab in combination with lenalidomide and dexamethasone is not U.S. Food and Drug Administration (FDA) approved for the treatment of smoldering multiple myeloma. Moreover, this medication regimen is not supported by major drug compendia or the medical literature. Landgren and colleagues reported that their findings support monotherapy with daratumumab in this clinical setting. Given these findings, the requested Revlimid (lenalidomide) combined with dexamethasone and daratumumab to be administered over an initial six-month period and forward is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for pulmonary ablation for treatment of the enrollees metastatic renal cell cancer. Findings:  The physician reviewers found there is sufficient support for the requested services in this clinical setting. Cryoablation is frequently considered in patients with renal cell carcinoma for distant metastases and is less invasive than surgery. Several large studies evaluating cryoablation for the treatment of intrathoracic lesions have revealed that the treatment is an effective and safe option. For this patient, it is less invasive than surgery or radiation, especially given multiple prior lung lesions that have been treated. Therefore, the requested pulmonary ablation is likely to be of greater benefit than other treatment options in this patients case. Final Result: Two of three reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications:  Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in medical oncology and actively practicing. The reviewers arte 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.