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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for omalizumab (Xolair). The current peer-reviewed medical literature has demonstrated that Xolair can provide improvement in symptoms in mast cell activation syndrome patients. Lemal and colleagues reported that Xolair is a useful therapeutic option to control mast cell-mediator symptoms and displays a favorable safety profile. Similarly, Molderings and colleagues found that Xolair can lessen the intensity of the symptoms of systemic mast cell activation disease. Given this patients attempts at treatment with oral cromolyn, doxepin, montelukast, methylprednisone, and imatinib, the requested six month trial of Xolair is appropriate. Therefore, the requested omalizumab (Xolair) is medically necessary for 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 subspecialty certification in allergy and  immunology 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

The parent of an 8-year-old female enrollee has requested ultraviolet B phototherapy administered in the home for the treatment of her scleroderma. Findings:  Three physician reviewers found that although there are case reports of linear scleroderma responding to narrow band UVB, this therapy has not been demonstrated to be effective in the majority of patients. An outpatient trial to assess response would be appropriate before using a home unit, particularly in light of the shallower penetration of UVB compared with UVA. Furthermore, if this patients condition is causing serious impairment, further systemic therapy should be considered.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested for a referral to a neurologist, an MRI and/or a full body CT scan for treatment and evaluation of her condition. Findings:  The physician reviewer found that there is no role for CT or MRI imaging as a screening test for diffuse pain.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for combination of Opdivo (nivolumab) with Yervoy (ipilimumab) every three weeks. This patient presents with recurrent malignant neoplasm of parotid gland status post right parotidectomy and adjuvant radiotherapy, repeat resection in with myocutaneous flap placement and adjuvant therapy. A recent computed tomography (CT) of the soft tissue of the neck revealed a 13 mm enhancing lesion, and evidence of extensive locoregional disease recurrent along the anterior and posterior margins of the flap, with index lesions. The patient was started on a regimen of Yervoy and Opdivo, which has been shown to yield a positive response in specific types of cancer, such as melanoma. However, there is a paucity of medical literature or guidelines reporting on the long-term safety and efficacy of the regimen consisting of Yervoy and Opdivo in the treatment of salivary gland cancer. Therefore, the combination of Opdivo (nivolumab) with Yervoy (ipilimumab) every three weeks forward was not and is 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 combination of Opdivo (nivolumab) with Yervoy (ipilimumab) every three weeks forward was not and is 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 medication regimen at issue was not and is 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 reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in medical oncology and is 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 47-year-old female enrollee has requested a cryotherapy machine for the treatment of her medical condition status post bunionectomy. Findings:  The physician reviewer found that the cryotherapy unit was not medically necessary for the treatment of this patients medical condition. While post-operative site cooling is extremely important and efficacious, it can be accomplished just as well with standard ice packs versus a cryotherapy unit. The standard ice pack method is generally accepted and utilized by most practitioners and renders a cryotherapy unit unnecessary. Further, a review of the medical literature does not reveal evidence that a cryotherapy unit provides superior cooling as compared to standard methods.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Nutropin AQ Nuspin 10 injector (quantity five, 30-day supply) and BD mini pen needles. Findings:  The physician reviewer found that Grimberg and colleagues report that idiopathic short stature (ISS), also called non-growth hormone-deficient short stature, is defined by a height standard deviation (SD) score at or below -2.25 SD and associated with growth rates unlikely to permit attainment of adult height in the normal range. The authors note that the height cutoff of -2.25 SD corresponds in adults to 63 inches for North American men. In this case, the patients growth chart and available clinical records do not demonstrate height Z-scores over -2.25 SD.  The records did not document normal brain magnetic resonance imaging (MRI), with and without gadolinium contrast, which is generally obtained before initiation of somatotropin. While direct height measurements of both biologic parents are preferred in cases of suspected growth disorders, the records included apparently self-reported parental heights, which may be significantly unreliable. The records documented that since the patient had entered puberty, his bone age had advanced slightly and yielded a predicted adult height of 63 inches, overlapping the lower limit of the normal range for North American men and consistent with his mid-parental target height (MPTH). Given that this patients growth pattern, pubertal timing, and bone ages have been consistent with his familial pattern of growth and development, and as patients recent growth velocity is within the normal range for early Tanner stage 2 in a male, the requested medication and supplies are not medically indicated. Therefore, Nutropin AQ Nuspin 10 injector (quantity five, 30-day supply) and BD mini pen needles are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication and supplies 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 pediatrics with sub-specialty certification in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections in the right knee. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees osteoarthritis in the right knee. The submitted documentation does not support the medical necessity of the requested Orthovisc injections. Guidelines for Treatment of Osteoarthritis of the Knee do not recommend hyaluronic acids for patients with symptomatic osteoarthritis, based on strong evidence. Fourteen hyaluronic acids studies were analyzed, and it was noted that a few individual trials found statistically significant treatment effects, but when combined in a meta-analysis, the evidence did not meet their minimum clinically important improvement thresholds. The American College of Rheumatology and Osteoarthritis Research Society makes no official recommendation regarding hyaluronic acids. The U.K. National Institute for Health and Care Excellence does not recommend hyaluronic acids. Therefore, the requested Orthovisc injections are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested treatment 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 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: An male enrollee has requested authorization and coverage for one hour of occupational therapy (OT) at the frequency of three sessions per week for treatment of the enrollees autism. Findings:  The physician reviewer found that the request for one hour of OT at the frequency of three sessions per week has not been established as medically necessary for treatment of the patients medical condition. There is evidence in the peer-reviewed literature that supports occupational therapy as effective for addressing sensory processing issues for children with ASD. However, there is a lack of research indicating how many hours of OT are needed. In this case, per the OT assessment, 30 minute sessions at the frequency of three sessions per week was recommended due to the patients attention span. Given the patients limited attention span, the request for one hour sessions of OT is not clinically indicated. Moreover, the treatment plan notes that once the patients attention span has increased, then longer treatment sessions may be indicated. Accordingly, the request for one hour of OT at the frequency of three sessions per week is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested duration of therapy 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 pediatrics with sub-specialty certification in developmental and behavioral 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 49-year-old male enrollee has requested for an MRI of the brain for evaluation of his dizziness. Findings:  The physician reviewer found that there is no medical indication for an MRI scan since vertigo following a closed head injury relates to injury of the vestibular apparatus (posttraumatic vestibulopathy or cochlear concussion). No pathology of the vestibular apparatus was seen by CT, and MRI imaging would not add any further diagnostic data.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a male enrollee requested 50 hours per month of applied behavior analysis therapy, plus six hours of supervision, one hour of staff or parent training and two hours per month of treatment planning for medical treatment of the enrollees autism spectrum disorder.  Findings:  Two physician reviewers found that Mohammadzaheri and colleagues examined whether applied behavior analysis was more effective or just using the applied behavior analysis technique of pivotal response training would be more effective.  The authors found that pivotal response training was more effective.  Thus, training multiple providers about basic behavioral techniques and pivotal responses may be appropriate to address this patients ongoing behavioral challenges. Abrupt discontinuation of applied behavior analysis is likely to lead to considerable regression and increase in behaviors.  However, a plan to decrease services over the next year is indicated.  Additional hours for parent training and treatment planning are not medically necessary. All told, a portion of the requested services is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 58-year-old man with small cell lung cancer diagnosed in April 2003. He was aggressively treated with chemotherapy and received cranial irradiation. Chemotherapy continued on and off until May 2004, when during chemotherapy he developed trouble speaking. Following chemotherapy, a CT scan revealed four lesions in the cerebrum. An MRI scan revealed a few more lesions with the largest measuring 17mm. Because of previous cranial irradiation the patient was referred for gamma knife radiosurgery. The Health Plan has denied authorization for gamma knife radiosurgery due to the multiplicity of the cranial lesions. The patient consulted another provider who concurred with the recommended gamma knife radiosurgery. Meanwhile, the patients central nervous symptoms have returned and are poorly controlled with steroids and Dilantin. The patient has stage IV small cell cancer of the lung. He has received prior cranial irradiation with good response. He now has new intracranial metastases with the largest lesion measuring 17mm. The choices of radiation management are between gamma knife radiosurgery and external beam cranial irradiation. Gamma knife radiosurgery is a proven therapy and has been recommended by two of the patients providers. The fact that the patient has multiple lesions is not a contraindication to the procedure. Gamma knife radiosurgery is a medically appropriate and indicated procedure. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested intensive outpatient (IOP) services, at a minimum of four times a week for treatment of the enrollees behavioral health condition.  Findings: The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue. The patient showed improvement in that he was better able to communicate with his peers, therapists, and parents. He demonstrated a better capability to effectively express his feelings and thoughts. The patient did require further treatment to continue to work on his coping and communication skills. The patient did not represent a threat to himself or others.  The patient was medically and psychiatrically stable. The patient was not psychotic or manic.  The patients problems with impulsivity and distractibility may have correlation between his substance abuse and ADHD. However, it was unclear from the submitted records why the patient was not seen by a psychiatrist for a psychotropic medication evaluation given the patients reported ADHD. In this patients case, the documentation does not support the treatment of four times per week at the IOP level of care.  Instead, IOP services, at two times per week, were medically necessary for treatment of this patient. The services were not and are not medically necessary.Final Result: The reviewer determined that a portion of the services at issue was and is medically necessary for treatment of the patients medical condition. Specifically, the IOP services, at two times per week, were medically necessary for treatment of this patient. The services forward were not and are not medically necessary. Therefore, the Health Plans denial should be partially 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested ribavirin and sofosbuvir (Sovaldi) for treatment of her chronic hepatitis C virus genotype 2. Two physician reviewers found that per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment guidelines, the recommended regimen for treatment naive patients with hepatitis C virus genotype 2 is daily sofosbuvir and weight-based ribavirin for 12 weeks. In addition, the guidelines cite three clinical trials demonstrating the safety and effectiveness of this medication regimen in patients with genotype 2 hepatitis C. Based on the provided records, published evidence of safety and efficacy in the published literature and clinical guidelines, the requested ribavirin and sofosbuvir (Sovaldi) should be approved as medically necessary for treatment of this patients medical hepatitis C virus.  Final Result: Two reviewers determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested radioembolization (selective internal radiation therapy with resin microspheres) for treatment of her medical condition.  Findings:  Two physician reviewers found that there is sufficient support in the peer-reviewed literature for the requested services in this clinical setting. In general, radioembolization has durable response and tends to better tolerated than transarterial chemoembolization (TACE). There are a number of prospective and retrospective studies which document the safety and efficacy of Yttrium-90 embedded spheres. In addition, radioembolization is within the generally accepted professional medical standards as being safe and effective. Sato and colleagues investigated 137 patients who underwent 227 administrations of Yttrium-90 microspheres for liver metastases. Four of these patients had renal cell carcinoma.  For all lesions in all patients, 87% experienced a biologic response. In the study by Abdelmaksoud and colleagues, six patients with metastatic renal cell carcinoma underwent eight radioembolizations. After a mean follow-up of more than 2 years, three patients had a complete response, and one patient had a partial response. A case report Hamoui and colleagues describes a patient with good response and better than expected survival after radioembolization for renal cell carcinoma. For patients with bulky liver disease, with a lack of therapeutic options, who have previously undergone systemic therapy, treatment with radioembolization is clinically indicated. In this case, the patients quality of life can be substantially improved with liver-directed therapy. Moreover, liver directed therapy has a reasonable likelihood of preventing (or delaying) symptomatic progression. As such, the requested services are likely to be more beneficial for treatment of the patients medical condition than any standard treatments.  Final Result: Two 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: All three reviewers are board certified in radiation oncology and are actively practicing. All three 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.