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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia. The Health Plan has denied this request and reported that the services at issue were not medically necessary for treatment of the enrollee, who underwent a colonoscopy. Per the medical evidence, monitored anesthesia care is warranted in prolonged or painful procedures, such as complex polyp resections, endoscopic retrograde cholangiopancreatography, endoscopic dilation, or endoscopic resection. Additionally, monitored anesthesia care may be necessary in patients with a failed history of moderate sedation for the procedure or psychological impediments to cooperation. The provided records do not support any of these criteria, or other criteria in the literature, such as difficult intubation, airway obstruction, allergies to sedation medications, increased aspiration risk, American Society of Anesthesiologists (ASA) class III or higher, or morbid obesity. In this patients case, the records do not support the medical necessity of monitored anesthesia care. All told, anesthesia was 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 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: Upheld

A 28-year-old female enrollee has requested ongoing physical therapy for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  As of the date indicated, the patient was noted to have no pain and no symptoms and was discharged from physical therapy.  While she may intermittently have some ongoing symptoms, she has undergone sufficient physical therapy to be independent with a home exercise and modality program.  Per the medical records, the patient does not have any significant impairment that would preclude her from performing an independent program. There are no documented exercises that she was performing in the formal therapy setting that she cannot perform independently, or substitute with independent exercise.  There is no proven benefit of passive modalities provided in a formal setting on a prolonged basis on health or functional outcomes in this clinical setting.  Palliative modalities such as topical heat can be applied independently by the patient without anticipation of a marginally significant difference in health or functional outcomes compared to modalities provided on a prolonged basis in the formal physical therapy setting.  No marginally significant benefit would be expected from the proposed ongoing formal treatment over an independent program.  All told, ongoing physical therapy is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Wegovy. The records document that this patient has a history of obesity. The provider reports that the patient has undergone diet and exercise changes without substantial weight loss. The patients provider has recommended treatment with Wegovy. Although lifestyle modification is recommended as the cornerstone of obesity management, many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss (Gadde, et al.). There are currently multiple pharmacologic therapies which are available for weight management. Wegovy is a member of a class of medications known as glucagon-like peptide-1 (GLP-1) agonists, which have been shown to improve glycemic control, reduce body weight, and decrease cardiovascular risk (Knudsen and Lau). Multiple studies have demonstrated the efficacy of Wegovy in the promotion of weight loss, via reduced appetite and energy intake, and delayed gastric emptying (Cornell). For these reasons, the requested Wegovy is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication 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 subspecialty certification in endocrinology, diabetes, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for urgent knee surgery for repair of a torn anterior cruciate ligament (ACL) and meniscus. In the medical literature, researchers reported on a study of 549 patients with ACL injury. The frequency of meniscal tear and location of tear were compared between acute and chronic ACL deficiency. The incidence of meniscal tear diagnosed by arthroscopic examination was 79.2% in all patients and 84.8% in the chronic group. Early ACL reconstruction is therefore recommended for the prevention of secondary meniscal tear. The records document that this patient has chronic instability of the left knee due to ACL deficiency with unpredictable episodes of giving way of the knee. Considering the patients history of frequent falls, the requested surgery should be performed on urgent basis to prevent additional trauma. The documentation also indicates a complex tear of the posterior horn and root of the medial meniscus which is the likely source of pain and joint effusion, and is contributing to the patients knee instability. The MRI scan report of 7/30/18 does not describe any arthritic changes in the joint. Given these findings, surgical reconstruction of the ACL and management of the medial meniscal tear is medically necessary. For these reasons, the requested urgent knee surgery for repair of a torn ACL and meniscus is supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld

A 58-year-old male enrollee has requested authorization and coverage for Rituxan for treatment of his membranous nephropathy. Findings:  Two physician reviewers found that the current medical literature supports a trial of steroids and cyclophosphamide at the first-line of management in this clinical setting.   Fervenza and colleagues and Ruggenenti and colleagues have published studies indicating that rituximab (Rituxan) is useful in inducing remission of nephrotic syndrome and proteinuria.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested genetic testing for cancer for medical evaluation of the enrollee, who has a family history of uterine cancer.  Findings:  The physician reviewer found that screening for germline mutations in colon cancer susceptibility genes is warranted in select patients in order to identify the presence of the hereditary non-polyposis colorectal cancer (HNPCC) or Lynch syndrome.  All told, the requested genetic testing for cancer is medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his hepatitis C virus genotype 1a.   Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The AASLD and IDSA guidelines recommend that all patients should be treated regardless of fibrosis stage. The guidelines do not recommend restriction of treatment to Centers of Excellence or to specific physician specialties except in certain cases of re-treatment, decompensated cirrhosis, and post-transplant treatment. The guidelines recommend that treatment-naive genotype 1a patients with or without cirrhosis should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). The AASLD and IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection.  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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested speech therapy for treatment of the enrollees language delay. Findings: The physician reviewer found that the article by Law and colleagues speech therapy interventions are effective for articulation disorders and expressive language disorders.  The authors also noted improvements in mean length of utterance and in expressive language on standardized testing.  The review by the physician and colleagues recommends continuing to screen for speech and language delay in children under age 5.  The authors found that the PLS-4 was the gold standard in most articles.  However most of these studies used a cut off of more than 1.5 standard deviations below the mean or 25% to qualify for services.  This review again found that expressive language disorders improve with speech therapy while also improving quality of life.  The research supports, total language or expressive language, are better scores to look at when determining who qualifies for services.  This patient had a total language score that qualifies him for speech services.  In sum, the request for speech therapy is medically necessary.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested acupuncture services for treatment of her knee pain.  Findings:  The physician reviewer found that the submitted medical records do not demonstrate the medical necessity of the requested service.  The patients diagnosis of osteoarthritis in her bilateral knees is unsupported by physical exam, orthopedic exam or x-ray findings. Moreover, the documentation does not indicate a limitation on her daily living activities nor are there any disabilities described. The records do not include a pain scale or an assessment showing improvement as a result of a trial of treatment. As such, the requested acupuncture is not medically necessary for treatment of the patients knee pain.  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 oriental 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: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP). The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition.The submitted documentation fails to demonstrate the medical necessity of the services at issue in this clinical setting. The patient was reported as making progress. The patients parents are supportive of the patient and are involved in family counseling. The patient denied any suicidal or homicidal ideation or psychosis. The patient was noted to be making progress in her treatment goals. The patient was able to attend to her activities of daily living. The patient was able to be treated in a less restrictive environment attending community 12-step programs and having sober supports. Therefore, while the patient continues to require treatment for her behavioral health condition, treatment could have been accomplished in a less restrictive environment such as a routine outpatient environment. As such, the services at issue have not been demonstrated as medically necessary for the treatment of this patients medical condition.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.Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 36-year-old female enrollee has requested percutaneous kyphoplasty for treatment of her spinal compression fracture. Findings:  Two physician reviewers found that there is no proven benefit to performing kyphoplasty this early following a compression fracture. The patient has only tried bracing and medical management for a short time. The medical literature suggests that younger persons with compression fractures heal and do very well with bracing for three months. The medical literature does not support kyphoplasty over conservative management this soon after compression fracture. The patient should be afforded more time to heal with the use of a brace and pain medications before kyphoplasty is considered.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested Harvoni for medical treatment of her hepatitis C.  Findings:  Three physician reviewers found that per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, patients with chronic active hepatitis C should be treated regardless of fibrosis score.  The evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy due to non-liver-related comorbid conditions.  This treatment may reduce liver-related adverse consequences, including end-stage liver disease and hepatocellular carcinoma.  All told, the requested Harvoni is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 12-year-old female enrollee has requested for injections/infusions of the medication Remicade for treatment of the enrollees Takayasus arteritis. Findings:  Three physician reviewers found that this patient has received the standard therapy for Takayasus arteritis. At this time, Remicade is likely to be more effective than other available treatment alternatives. This patient has received standard of care treatment for Takayasus arteritis, and her disease is still active. The medical evidence demonstrates that Remicade is a safe and effective treatment in this clinical situation.
Appeal type: Experimental/Investigational
Decision: Overturned

A 37-year-old female enrollee requested authorization and coverage of cardiac catheterization with placement of the amplatzer occluder for the treatment of a 12mm congenital atrial septal heart defect (ASD).  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that cardiac catheterization with placement of the amplatzer occluder is likely to be more beneficial for treatment of the enrollees 12mm congenital atrial septal heart defect than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization overturned the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 12-year-old male enrollee has requested eye movement desensitization and reprocessing (EMDR) as an adjuvant therapy along with cognitive behavioral therapy for treatment of the enrollees post traumatic stress disorder (PTSD).  Findings:  The physician reviewer found that review of the submitted documentation and peer-reviewed literature demonstrates the medical necessity of the requested therapy. Trauma-focused cognitive behavioral therapy has the best evidence in the peer-reviewed medical literature for the treatment of PTSD in adolescence. Although there are no definitive studies illustrating the effectiveness of EMDR in this population, EMDR is an established non-invasive therapeutic intervention for adults diagnosed with PTSD, and is included in the American Academy of Child and Adolescent Psychiatrys practice parameter for treatment of children and adolescents with PTSD.  Considering this recognition, coupled with the fact that this patient with profound psychiatric impairment has responded well to the therapy, utilizing EMDR as an adjunctive modality is safe and reasonable in this particular case, and thus medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested residential treatment center services for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the submitted records demonstrate the medical necessity of a portion of the services at issue.  Although the patient was said to be easily frustrated, there were no episodes of emotional outbursts/lability described.  Initially, she was reported to be inattentive, impulsive, and hyperactive.  She was cooperative with staff.  She participated in her treatment and in groups.  She was doing better in school.  She subsequently began developing insight and started to recognize behavior patterns she engaged in with her parents.  She was learning to calm herself and practice emotional regulation with different responses.  All told, the medical records demonstrate the medical necessity of residential treatment center services initially, but not thereafter.  Final Result: The reviewer determined that a portion of the services at issue was 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for chiropractic services. Findings:  The physician reviewer found that there is a lack of evidence in current medical literature to support spinal manipulation for a diagnosis of hip pain. While the patient reported diagnoses of cervical disc disorder with radiculopathy and lumbago with sciatica on the left side, the submitted records did not include  documentation from a medical provider supporting these diagnoses. The patient reported undergoing chiropractic services, however, notes from these sessions were not included for review. Given that current medical literature does not support the use of chiropractic manipulation of the spine for the treatment of hip pain, the requested services are not medically indicated. Therefore, chiropractic services are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in chiropractic 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: Overturned

A 44-year-old female enrollee requested the combination of pertuzumab, trastuzumab and tamoxifen, for use without chemotherapy for medical treatment of her metastatic breast cancer.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication combination in this patients case.  Newly approved biologic and chemotherapy agents have improved overall survival and quality of life for patients with metastatic breast cancer.  The combination of pertuzumab, trastuzumab and tamoxifen, for use without chemotherapy is medically indicated for the treatment of this patient.