Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

A 47-year-old male enrollee has requested for a Saunders Home Lumbar Traction device for treatment of his left sided sciatica and probable disc herniation.  Findings:  Three physician reviewers found that the medical literature includes articles about traction devices that range from quite elaborate systems to simple devices that depend on the individual providing their own power to support the pulling action of the traction. Some of the articles support the use of lumbar traction, while others were unable to demonstrate any benefit with a lumbar traction device. However, the available evidence does not establish that the at home use of a traction device such as the Saunders unit is superior to other modalities such as bed rest, physical therapy and/or medications. The medical literature simply does not suggest that a home traction device is more beneficial than any other available, standard treatments.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for direct one-on-one applied behavioral analysis (ABA) therapy services, to be provided from a therapist while in school. This patients provider listed 13 goals and of these goals, three of them require peer interaction. However, since only a few of the patients ABA treatment goals require peer interaction, these goals can be completed in the home or community settings. Based on the current medical literature, there are sufficient goals to justify ABA services to be provided in the home setting for this patient. Moreover, this patients provider did not provide specific rationale to support services to be provided in the school setting in lieu of the home setting. As progress is made, future services may include the educational setting as an opportunity to practice generalization of skills. Medical literature highlights that in order to ensure continuity of care, sufficient ABA treatment and consultation should be delivered in subsequent educational and therapeutic settings. At this juncture, ABA services within the home are appropriate, and have been approved by the Health Plan. All told, direct one-on-one ABA therapy services, to be provided from a therapist while in school, are not medically necessary for treatment of this patients behavioral health issues. 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 psychology and is a board certified behavior analyst 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 male enrollee requested Harvoni for medical treatment of hischronic hepatitis C virus genotype 1a.  Findings:  Three physician reviewers found that the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment guidelines state that successful hepatitis C treatment results in sustained virologic response, which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. In addition, the guidelines state that treatment is assigned the highest priority for those patients with advanced fibrosis (Metavir F3), those with compensated cirrhosis (Metavir F4), liver transplant recipients, and patients with severe extrahepatic hepatitis C. This patient has a Metavir of F2-F4, which is consistent with an F3 and short of having cirrhosis. Thus, the requested Harvoni is supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

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

A 62-year-old female enrollee has requested the prescription medication Sonata for the treatment of her insomnia. Findings:  The physician reviewer found that this patient has sleep maintenance insomnia, not sleep initiation insomnia. Out of the three benzodiazepines on the market, Sonata (zaleplon) is the best option for this type of insomnia. It has the shortest half life and a decreased the risk of hangover effect. Other agents such as benzodiazepine agonist or hypnotics are not appropriate given the prolonged half-lives. Treatment with Ambien or Lunesta is not equivalent to or exchangeable for treatment with Sonata in this instance.
Appeal type: Urgent Care
Decision: Upheld

A 43-year-old female enrollee has requested ambulance services for treatment of her lower abdominal/pelvic pain.  Findings:  The physician reviewer found that a prudent layperson would not have sought ambulances services in this situation. The patients pain was of gradual onset, had been going on for 5 days, was not associated with abnormal vital signs, was not associated with abnormal physical findings as recorded by the paramedics, and was only rated as moderate (level 4/10). A prudent layperson would not have thought this to be an emergency medical condition and would not have sought ambulance services for immediate medical attention. There was no evidence to lead a prudent layperson to believe that ambulance services were necessary to address a serious medical threat. For the reasons set forth above, the patients symptoms did not meet prudent layperson criteria for the ambulance services provided on the date indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested admission to an inpatient recovery program for treatment of the enrollees behavioral health condition.  Findings: The physician reviewer found that the documentation does not support the medical necessity of the requested services. The records do not show that this patient had enduring efficacy following a treatment course identical to the requested service. The records reviewed indicate the patient previously participated and completed an equivalent recovery program as the one being requested.  Consequently, another iteration of the same program would not be reasonably expected to improve the patients condition or prevent an exacerbation of the addictive illness.  Moreover, the documentation does not advocate a more restrictive setting for the treatment of this patient, nor do the records describe the patients current status, treatment needs and barriers to care.  Therefore, an outpatient, community-based services would be medically appropriate for the treatment of this patient per the records submitted. As such, the requested authorization and coverage for admission to a 60-day inpatient recovery program is 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 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 72-year-old male enrollee has requested Bystolic 10mg for treatment of his hypertension. Findings:  The physician reviewer found that this patient is being treated with Bystolic, a non-formulary drug, for the management of hypertension. The only other beta blocker trial documented was atenolol, and this was not tolerated due to cold hands and toes with Raynauds syndrome. The medical records do not document treatment failure or intolerable side effects to other formulary beta blockers. Bystolic is a beta-1 selective beta blocker at the dose prescribed. There are alternative formulary beta-1 selective beta blockers available, including metoprolol, bisoprolol and acebutolol. These should not result in the beta-2 side effects that this patient experienced with atenolol. In this patients case, the alternatives offered by the Health Plan are medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for consultation with a neurosurgeon. Findings:  The physician reviewer found that the provided documentation does not support the medical necessity for the requested services in this clinical setting. The record notes that the patient was seen and evaluated by a board certified fellowship trained spine surgeon. The patients cervical spine x-rays were reviewed and interpreted by this provider. A cervical examination was performed.  The surgeon recommended an ACDF at C5-6. As such, the documentation fails to support a medical reason for an evaluation of this patient by a neurosurgeon. Therefore, the consultation with a neurosurgeon is not medically necessary for the evaluation of this patients medical condition. 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 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

The representative of an eight-year-old female enrollee has requested Genotropin (growth hormone) for the treatment of the enrollees short stature. Findings:  The physician reviewer found that this patient has not exhibited catch-up growth. Additionally, her workup is unrevealing. This patients bone age was modestly retarded. At 8 years 2 months of age, her bone age was 7 years 10 months. Based upon the submitted documentation and the Greulich and Pyle Hand Atlas, the patients predicted adult height without treatment is 57.5 inches.  This patient meets the Food and Drug Administration guidelines for the use of growth hormone for small for gestational age children who have not caught up with their peers. The use of growth hormone therapy in this setting is also consistent with guidelines published by the American Association of Clinical Endocrinologists. All told, the patient is an appropriate candidate for Genotropin, which is medically indicated in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested reimbursement for Decision-Dx Genetic Testing. The American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. In the current AJCC staging system, Clarks level has prognostic significance only in patients with very thin melanomas, which is defined as a Breslow depth less than 1 mm. The DecisionDx-Melanoma gene expression profile (GEP) test is an expression assay designed to predict distant metastasis in stage I and stage II melanoma patients. Evidence from five cohort studies suggested that the test has prognostic value for assessing recurrence-free survival, distant metastasis-free survival, and overall survival. This patient presented with a tumor with a Breslow depth of 0.9 mm. According to the results of analysis of this patients analysis performed with DecisionDx-Melanoma, the tumor was classified as a low risk of near-term metastatic disease. Therefore, additional testing in this clinical setting was not expected to add novel useful data relevant to this patients decision planning. For these reasons, the Decision-Dx Genetic Testing was not likely to be more beneficial for evaluation 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 evaluation 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 dermatology 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

The parent of an 11-year-old female enrollee has requested occupational therapy for feeding twice a week for 16 weeks (32 visits) for treatment of the enrollees feeding disorder due to chromosomal abnormality. Findings:  The physician reviewer found that based upon the records provided, the patient has failed to alter her dislike for most foods despite two four-month courses of weekly occupational therapy. Manckam and colleagues report that successful results in cases involving severely developmentally delayed children requires a structured approach involving multiple disciplines, including a gastroenterologists assessment, which based upon the documentation provided, it does not appear this patient has received. In summary, this patient is achieving adequate nutrition, despite her limited food choices. There is no evidence she had undergone a complete gastroenterological assessment which could be helpful in pinpointing problems and could result in an improvement in her selection of foods. Her past occupational therapy has failed to result in measurable improvement and there is no indication that additional occupational therapy at this time is likely to result in improvement of the patients diet. As such, the medical necessity of occupational therapy for feeding has not been established.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old male enrollee has requested Lyrica for treatment of his autonomic dysfunction/ chronic regional pain syndrome of the lower extremities. Findings:  The physician reviewer found that the patient has CRPS with constant moderate to severe pain. He has failed all of the usual treatment modalities and the usual medications which have included tricyclic antidepressants and anticonvulsants. Lyrica has reportedly given him symptom relief over the past five to six months. The safety of Lyrica has been sufficiently tested in other clinical applications and this medication has become a standard of care in the management of  dozens of neuropathic pain syndromes outside of the indicated post herpetic neuralgia and diabetic neuropathy.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old female enrollee requested authorization and coverage of the medication Neupogen. The Health Plan denied the request indicating that the requested medication is not medically necessary while the enrollee is undergoing chemotherapy.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 39-year-old male enrollee has requested Lexapro 10mg for treatment of his major depression.  Findings:  The physician reviewer found that per the patient and the treating physician, Celexa lost its effectiveness after several years.  He was subsequently switched to Lexapro 10mg per day.  This is working well, per the treating physician.  Montgomery and colleagues noted the statistically significant superiority of escitalopram (Lexapro) compared to citalopram (Celexa).  Garnock-Jones and McCormack noted the efficacy of Lexapro for major depressive disorder.  Given the patients positive response, it would be clinically inappropriate to discontinue Lexapro and risk relapse with a trial of a different medication.  All told, Lexapro 10mg is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee requested authorization and coverage for Proton Beam Radiation Therapy, 28 fractions for their medical condition of prostate cancer.  The use of proton beam therapy is not the current standard of care, requires further investigation and would therefore not be considered medically necessary in this case.  Specifically, there is no evidence that the IMRT plan cannot safely deliver the radiotherapy.  Quantec dose guidelines report that when individual loops of bowel are contoured, it is recommended to limit the V15 of the small bowels to 120cc.  There is no demonstrable clinical advantage to the proton beam therapy over IMRT based on the treatment plan comparison. Therefore, Proton Beam Radiation Therapy is not medically necessary. The health plans denial of coverage and authorization should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for LINX procedure (placement of esophageal sphincter augmentation device) for treatment of the enrollees gastroesophageal reflux disease (GERD). Findings:  Two physician reviewers found that There is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures. Researchers in Current Opinion in Gastroenterology, concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined. Another best-evidence review concluded that long-term comparative outcome data past 1 year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval. One peer-reviewed journal published a letter stating that there are 11 reports of endoscopically-confirmed LINX erosion through the esophagus in the publicly-accessible FDA Adverse Events database. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is likely to be more beneficial than standard treatment. American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. Final Result: The reviewers determined that the requested services are 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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 32-year-old male enrollee requested inpatient treatment for behavioral health issues.  Findings:  The physician reviewer found that based on the available medical documentation, by the date in question this patient was no longer presenting as gravely disabled or considered harmful to himself or others. He was noted to be tolerating his medication regimen without intolerance, or adverse effects. He remained hyper-religious and grandiose in his thinking, but was calm, cooperative and not requiring 24-hour supervision, monitoring, or treatment. As such, he could have been considered for ongoing psychiatric and chemical dependency services in a less restrictive setting. The treatment provided at the specified inpatient treatment facility does not meet the American Psychiatric Association (APA) criteria for inpatient services. Therefore, the services at issue were not and are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee requested authorization and coverage of the medication Vicodin. The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollees chronic thoracic myofascial pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Emgality (galcanezumab). The International Headache Society (IHS) defines chronic migraines as headaches for more than 15 days monthly for longer than three months that are not attributable to another disorder and include at least two of the following characteristics: unilateral, pulsatile, moderate to severe in intensity, or aggravation by or causing avoidance of routine physical activity. The criteria also require that the symptoms include one of the following characteristics: nausea, vomiting, photophobia, or phonophobia. Medical literature notes that treatment of chronic migraines with Botox is associated with significant and clinical meaningful reductions in headache impact and improvement in quality of life. Medical literature also notes that galcanezumab, a humanized monoclonal antibody that selectively binds to calcitonin gene-related peptide, appears efficacious, safe, and well tolerated for the preventive treatment of chronic migraine. Medical literature notes that dual therapy with anti-calcitonin gene-related peptide monoclonal antibodies and botulinum toxin type A may be an option in the treatment of patients that are resistant to monotherapy. In this case, the patient has chronic migraines and has treatment with tolerated Botox. Given that current medical literature does not note that concurrent calcitonin gene-related peptide inhibitor administration is a contraindication to the use of Botox, and as the patient reports ongoing migraines, the requested medication is medically indicated. Therefore, Emgality (galcanezumab) is 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 neurology 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.