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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for one hour of speech therapy weekly for six months. Smith and colleagues note, Language disorder is a cardinal challenge for children with Down syndrome. Eggers and Van Eerdenbrugh report, Speech and language development in individuals with Down syndrome is often delayed and/or disordered and speech dysfluencies appear to be more common. Lieu and colleagues note that hearing loss in children includes worse outcomes in speech, language, education, social functioning, cognitive abilities, and quality of life. Thus, speech therapy would be an important intervention in the development of effective communication for a child with hearing loss. Segura-Pujol and Briones-Rojas report that there are few articles published investigating treatment intensity in children with developmental language disorder. Byers and colleagues note that children with mild or mild-moderate speech sound disorders may benefit more from a shorter, frequent, individual service delivery model over twice weekly, 30-minute group sessions. In this case, the patient has a diagnosis of Down syndrome and bilateral hearing impairment. The records note that he has not done well with remote, Zoom therapies during the pandemic due to impaired hearing and a short attention span. Given that current medical literature supports the use of speech therapy in this clinical setting, the requested services are medically indicated. Therefore, one hour of speech therapy weekly for six months is medically necessary for the treatment of this patient. 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 neurology with special qualification in child 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vemlidy, 25 mg daily. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis B.Findings: Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Diseases (AASLD) recommend entecavir and tenofovir compared to alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), the Vemlidy formulation of tenofovir is effective for treatment of hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. As such, the request to switch the patient to Vemlidy to reduce the risk of tenofovir-related nephrotoxicity and loss of bone density is medically reasonable and appropriate. For these reasons, Vemlidy 25 mg daily is medically necessary for the treatment of this patients hepatitis B. 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 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 patient is a 56-year-old woman with irritable bowel syndrome (IBS) who has not responded to traditional therapies for this disorder. The records provided indicate the patient did respond to treatment with an approved therapy, Zelnorm. Since Zelnorm was discontinued the patients symptoms have returned. She has requested authorization for further treatment with Zelnorm. The Health Plan has denied this request on the basis that Zelnorm is not medically necessary for treatment of the patients medical condition.  Although the FDA approval for Zelnorm is limited to several weeks, IBS is a lifelong condition. It appears this patient has tried multiple other alternatives without relief. It also appears the patient has had a positive response to a low dose of Zelnorm. Since IBS is a chronic disease, it is well known that many patients will require re-treatment or require maintenance on Zelnorm in order to control their symptoms. Clinical experience with Zelnorm over the past two years provides sufficient evidence to support this pattern of use. In light of the information set forth above and given the patients good clinical experience with Zelnorm with no evidence of toxicity or side effects, continued use of Zelnorm is medically appropriate and indicated. Therefore, 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

A 43-year-old female enrollee has requested for gabapentin (Gralise) for treatment of her pain. Findings:  The physician reviewer found that the peer-reviewed medical literature has demonstrated that the requested medication is a safe and effective treatment for several neuropathic conditions.  Gilron reviewed evidence-based literature supporting the use of gabapentin and pregabalin for chronic neuropathic and early postsurgical pain.  The authors found that multiple, high-quality trials have demonstrated the safety and efficacy of gabapentin and pregabalin in neuropathic pain.  The review concluded that gabapentin and pregabalin are efficacious treatments for neuropathic and postsurgical pain. Gabapentin (Gralise) is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old female has requested the medication Byetta for treatment of diabetes.  Findings:  The physician reviewer found that this patient meets the criteria for approval of Byetta.  Byetta is not being used to replace insulin therapy. This patient is not an insulin dependant (or insulin requiring) diabetic, and she will not be using insulin with the Byetta.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female requested authorization and coverage for lap band removal and revision to a duodenal switch procedure. The Health Plan denied the request indicating that the requested procedure was not medically necessary for treatment of the enrollees morbid obesity.  Findings:  The physician reviewer found that this patient with morbid obesity was status post bariatric surgery with a laparoscopic adjustable gastric band. The submitted documentation reveals no evidence of overt complications of the procedure. An upper gastrointestinal series was normal and an EGD showed no erosion or slippage of the band. It appears dietary compliance may be an issue in this case as a consistent restrictive diet high in protein is not well documented. Based upon the submitted documentation, there is no evidence to support removal of the lap band and revision to duodenal switch at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee has requested for bilateral breast reduction for treatment of her condition.   Findings:  The physician reviewer found that there is no evidence of shoulder grooves, inframammary fold rashes, skin ulcerations or kyphosis.  There are no medications indicating treatment of rashes or intertrigo listed in the medication list. There is also no loss of function evident.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested emergency room services on an emergent basis.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates there were no signs of serious medical illness or discomfort in this patient. There is no evidence of pain, fever or systemic symptoms, and the patient had no underlying medical conditions. Based upon the chart notations, the patient did not appear uncomfortable in any way. A prudent layperson in this situation would not have believed the patient was experiencing an emergency medical condition. While the patients parent noted concerns about infection, the patient did not present with acute symptoms of infection. In this situation, a prudent layperson would have scheduled an appointment with the patients pediatrician on an outpatient basis. Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in emergency 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Supartz injections to the right knee.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the options are limited. The patient has undergone a right total knee replacement with the exception that the patella was not replaced. The provider has tried a cortisone injection without success. Thus, the Supartz injections to the right knee were medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: 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

A 53-year-old male enrollee requested authorization and coverage of proton beam therapy.  The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees prostate cancer.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Stretta antireflux procedure. Current medical literature does not demonstrate that the Stretta procedure is superior to laparoscopic Nissen fundoplication (LNF) in the management of gastroesophageal reflux disease (GERD). Medical literature notes that while both LNF and Stretta radiofrequency may effectively and safely control GERD symptoms in selected patients, LNF was superior in improving symptoms and in eliminating proton pump inhibitor (PPI) therapy dependence. Researchers found that while treatment with Stretta was more effective than PPI therapy, it was less effective than fundoplication. Therefore, the requested Stretta antireflux procedure is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Stretta antireflux procedure 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 requested service 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 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: Overturned

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for Mavyret 100-40 mg tablets for eight weeks. 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. The guidelines recommend that non-cirrhotic treatment naive genotype 2 patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage. A trial showed a 99% cure rate with eight weeks of treatment. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret 100-40 mg tablets for eight weeks 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: Experimental/Investigational
Decision: Overturned

A 64-year-old male enrollee has requested closure of a patent foramen ovale (PFO) for treatment of his patent foramen ovale.  Findings:  Two physician reviewers found that the American College of Chest Physicians (ACCP) guidelines recommend aspirin over no aspirin for patients with cryptogenic stroke and PFO or atrial septal aneurysm (ASA). For patients who experience recurrent events despite aspirin therapy, the ACCP guidelines suggest treatment with vitamin K antagonist therapy and consideration of device closure over aspirin. For patients with cryptogenic stroke and PFO who have evidence of deep vein thrombosis (DVT), the ACCP guidelines recommend vitamin K antagonist therapy for three months and consideration of device closure over no vitamin K antagonist therapy or aspirin therapy. In this patients case, given his presentation with recurrent TIAs despite being on aspirin it is medically indicated in this case to close the PFO. In sum, the requested closure of a patent foramen ovale is likely to be more beneficial for treatment of the patients medical condition than any other modalities.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the use of an electromyography (EMG) machine to guide the Botox injections for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity for the requested services. According to the documentation submitted for review, the patient presents with cervical dystonia and has been treated with Botox injections. The patient reports a significant relief when Botox injections are provided with the guidance of EMG. Researchers examined whether multichannel electromyographic mapping improved outcomes in a cohort of antibody-negative onabotulinumtoxinA non-responders by more precisely identifying which muscles were involved in the dystonia. The authors reported that EMG mapping may result in improved efficacy in treatment of cervical dystonia with Botox. In sum, there is support in the literature for EMG guidance for delivery of Botox for treatment of cervical dystonia. Therefore, the request for EMG machine to guide the Botox injections is medically indicated for this patient.  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 neurology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injection (hyaluronan) for treatment of knee pain due to osteoarthritis. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. Researchers have noted that medical guidelines recommend intra-articular hyaluronic acid for management of knee osteoarthritis as second-line treatment in patients who remain symptomatic despite use of non-steroidal anti-inflammatory drugs. This recommendation is based upon accumulating evidence that intra-articular hyaluronic acid provides a significant benefit in knee osteoarthritis. There is good evidence that intra-articular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intra-articular corticosteroids. Evidence from real-life studies of repeat courses of intra-articular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months (12 months after the last injection cycle), a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement (TKR) of around 2 years. The clinical benefit of intraarticular hyaluronic acid on knee osteoarthritis may be 2-fold: (i) mechanical viscosupplementation of the joint (allowing lubrication and shock absorption); and (ii) the re-establishment of joint homeostasis through induction of endogenous hyaluronic acid production, which continues long after the exogenous injection has left the joint. In addition, other researchers have conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. This review shows that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. As such, the requested services are medically necessary.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 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

A 54-year-old female enrollee has requested a panniculectomy, belt lipectomy/abdominoplasty for treatment of her excess skin condition. Findings:  The physician reviewer found that the surgery has been proposed as a treatment for recurrent infections, but the records provided do not include objective evidence to verify the accuracy of the patients history.  The patient does not have medical record documentation over time (e.g., series of office notes, dermatology consultations, pharmacy prescription records) of skin infections in the abdominal fold. Additionally, photographs documenting cellulitis, ulcerations or rashes have not been provided. The plastic surgeons consultation letter indicates that the patient has failed conservative treatment, but office notes confirming this to be the case are not submitted. There is no mention of specific dates on which the patient was treated for infections or specific medications used to treat these infections. Due to the absence of any office notes documenting infections, the patients history of uncontrollable and recurrent intertrigo cannot be verified.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for Synvisc One injection for treatment of the enrollees osteoarthritis of the left knee.Findings:  The physician reviewer found that current evidence-based guidelines and literature support repeated cycles of viscosupplementation treatment to delay time to total knee replacement in patients with knee osteoarthritis who failed conservative treatment. There is no maximum amount of injections established by high-quality scientific evidence. This patient presents with a history of left knee osteoarthritis. Functional difficulty has been documented in prolonged weight-bearing and with stairs, squatting, and getting up from a low sitting position. Conservative treatment has included exercise, corticosteroid injections, physical therapy, and medications. She has undergone prior Synvisc injections, with good benefit reported. The current medical evidence supports the requested service in this clinical setting.  All told, the requested Synvisc One injection is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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.