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

The patient is a 31-year-old man who has requested authorization and coverage for orthotics. Review of the documentation provided indicates that the patient is being treated for chronic heel pain secondary to calcaneal spur and plantar fasciitis. The patient has been treated with taping, local steroid injections, anti-inflammatories, and stretching with no relief of symptoms. The patients provider has recommended orthotics to control excessive pronation and reduce pull of the plantar fascia on the heel bone. The Health Plan has denied authorization for orthotics indicating the requested equipment is not medically necessary.The Health Plans denial should be overturned. Review of the submitted records indicates the patient has tried various forms of conservative treatment with no relief of symptoms.The medical literature supports orthotic therapy in cases where other conservative measures have failed. Custom corrective foot orthotics function by maintaining the rear foot in a biomechanically neutral position to prevent abnormal motion in the rear foot during gait. Orthotics also support the metatarsal joint and disperse abnormal pressure off the plantar fascia. By reducing this stress the chronic inflammation should subside in the majority of cases.Based upon the information set forth above, I have determined that the requested equipment 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 Sovaldi and Daklinza for treatment of his hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  For patients with hepatitis C, genotype 2 infection who are interferon-ineligible and have had failed therapy with Sovaldi and ribavirin, the guidelines recommended Sovaldi/Daklinza with or without ribavirin for 24 weeks.  For these reasons, the requested treatment with Sovaldi and Daklinza is medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer 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: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a male enrollee requested 18 hours per week of applied behavioral analysis (ABA) therapy for medical treatment of the enrollees autism spectrum disorder.  Findings:  Three physician reviewers found that children with autism with or without intellectual disability have challenging behaviors such as elopement and aggression that are very difficult to treat and often require intensive behavioral interventions. Hutchins and Prelock found that improving communication is one of the best ways to address challenging behaviors. In this clinical setting a reduction of ABA services is not indicated until the maladaptive behaviors are resolved. Thus, it is medically necessary for this patient to receive 18 hours per week of ABA therapy for treatment of his autism spectrum disorder.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old male enrollee requested authorization and coverage of the medication Cipro. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees gastroesophageal reflux disease (GERD).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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for incontinence medical supplies. The submitted documentation fails to demonstrate the medical necessity of the requested equipment. The treatment for mixed type urinary incontinence starts with lifestyle modifications, pelvic floor muscle exercises, and bladder training. If initial treatments are not effective, women are then treated based on their predominant symptoms. In this case, the request is for urinary incontinence supplies. The records do not include a detailed history of the patients urinary complaints. It is unclear if any diagnostic studies have been done or are even necessary. Furthermore, there is no clear documentation of her predominant symptoms or failed previous treatments. All told, the requested incontinence medical supplies are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine 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 55-year-old male enrollee has requested Xiaflex injections (clostridial collagenase histolyticum) for treatment of his Peyronies disease.  Findings:  Two physician reviewers found that Non-surgical treatments for Peyronies disease include oral medications vitamin E and Potaba, and injectable verapamil and interferon. The peer-reviewed medical literature does not support these therapies as effective for patients with Peyronies disease. Xiaflex has been shown to have modest efficacy in clinical trials and has been approved by the U.S. Food and Drug Administration (FDA) for use in patients with Peyronies disease with at least 30 degrees of curvature and a palpable plaque. For these reasons, the requested Xiaflex injections are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation therapy (28 fraction regimen of 70 Gy high dose). On review of the medical literature, there is a paucity of data demonstrating that treatment with proton therapy is associated with a clinical benefit compared to photon based radiation therapy. Vapiwala and colleagues reported on a recent multi-institutional analysis of 1,850 patients with low or intermediate risk prostate cancer who were treated with hypofractionated radiation proton therapy and intensity modulated radiation therapy with photons. The authors found no significant difference in disease control, or gastrointestinal or genitourinary toxicities between the two treatment modalities. Per the American Society for Radiation Oncology (ASTRO), Proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry. The ASTRO position statement noted further that the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. Moreover, the National Comprehensive Cancer Network (NCCN) guidelines endorse the position statement by ASTRO and state that no clear benefit of proton therapy has been demonstrated over standard treatment with photons and intensity modulated radiation therapy technique. In conclusion, the requested proton beam radiation therapy (28 fraction regimen of 70 Gy high dose) is not medically necessary for 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 radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Kineret 100 mg/0.67 mL syringe. This patient has been diagnosed with Erdheim-Chester disease, which is a malignant disorder that involves pro-inflammatory cytokines, most importantly, interleukin-1. The patients provider recommended treatment with Kineret, which is a recombinant form of an interleukin-1 receptor antagonist. Kineret is currently U.S. Food and Drug Administration (FDA) approved for rheumatoid arthritis and cryopyrin-associated periodic syndromes. Consensus guidelines, as reported in the American Society of Hematology, include Kineret as a viable treatment option in this clinical setting . Studies have demonstrated Kineret to be safe and effective in the treatment of patients with Erdheim-Chester disease. Therapies such as interferon alfa are not well tolerated and have variable efficacy. Given the support in the current medical guidelines and literature, Kineret is appropriate for treatment of this patients Erdheim-Chester disease. Therefore, Kineret 100 mg/0.67 mL syringe 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 certifications in medical oncology and hematology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dosage escalation of Entyvio 300 mg IV infusion to every four weeks. The request to continue Entyvio 300 mg every four weeks is supported as medically necessary for the treatment of this patients Crohns disease. In two randomized placebo-controlled trials, which supported U.S. Food and Drug Administration (FDA) approval, Entyvio was part of a study protocol for patients who had not achieved remission despite six weeks of treatment and continued Entyvio every four weeks rather than every eight weeks. The American Gastroenterological Association (AGA) indicated that for patients with Crohns disease, Entyvio every four weeks resulted in remission in over 36% of patients after one year. In addition, studies have shown that insufficient Entyvio dosing can result in uncontrolled disease and related complications. Per the American College of Gastroenterology (ACG) guidelines for the treatment of Crohns disease, patients with continued symptoms should have their medication dose adjusted in order to attempt to optimize therapy. For this patient, continued treatment with dose intensification is appropriate for infusion every four weeks. The patient has severe Crohns disease given history of surgery including an ileocecal anastomosis. Since the patients disease was uncontrolled on colonoscopy while on Entyvio, a dose decrease, discontinuation, or change to an alternative would place the patient at risk for complications of uncontrolled disease. For these reasons, the requested dosage escalation of Entyvio 300 mg IV infusion to every four weeks is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication dosage 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 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 49-year-old male enrollee requested authorization and coverage of an inflatable penile implant. The Health Plan denied the request indicating that the requested implant is not medically necessary for treatment of the enrollees medical condition.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: Upheld

The patient has requested reimbursement for residential treatment center (RTC) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the LOCUS framework, the patient did not meet the criteria for the RTC services. The patient has a composite score which is consistent with high intensity community-based services, such as intensive outpatient program (IOP) level of care. Given these findings, the psychiatric RTC level of care services were not medically necessary for 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 psychiatry with subspecialty certification in addiction 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

The parent of a six-year-old male enrollee has requested ambulatory cardiac event monitor with mobile cardiac outpatient telemetry (MCOT) for evaluation of the enrollees transposition of the great arteries status post arterial switch with evidence of sinus node dysfunction with an accelerated junctional rhythm as well as occasional junctional escape rhythm with pacemaker placement.  Findings:  The physician reviewer found that evaluation with MCOT provides real-time remote heart monitoring and automatically transmits an electrocardiogram (EKG) to a center for analysis. The service offers a diagnostic advantage when the patient is unable to activate the device, as in the case of syncope, and may be experiencing a life threatening arrhythmia. In the diagnosis of patients with symptoms of a cardiac arrhythmia, MCOT provides a significantly higher yield than standard cardiac loop recorders (Rothman and colleagues) . According to this patients medical records, the index of suspicion is low that the chest pain is caused by palpitations. He has a history of tachycardia and no potentially life threatening symptoms such as syncope. As such, immediate intervention is not likely to be required. For these reasons, real-time remote monitoring in this patient with MCOT is not medically necessary. Further evaluation with standard loop event monitoring is adequate to diagnose whether this patient is having a significant arrhythmia causing his chest pain.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Ensure formula.Poor nutrition is common in individuals with cerebral palsy and has a wide-ranging impact on their health and well-being (Rempel, G.). Ruiz Brunner and colleagues conducted a cross-sectional study to describe the nutritional status of children with cerebral palsy (CP) and to analyze their risk of undernutrition based on their Gross Motor Function Classification System (GMFCS) level. They found that there is a high prevalence of undernutrition associated with CP (GMFCS levels IV and V) and that risk of severe undernutrition increases with increased motor compromises. Bell and Samson-Fang note that children with severe cerebral palsy, and particularly those with oropharyngeal dysfunction, are at high risk of poor nutritional status. They note that first-line treatment typically involves oral nutritional support for individuals with cerebral palsy who are safe to consume an oral diet. Enteral tube feeding may need to be considered in individuals with undernutrition where poor weight gain continues despite oral nutritional support, or in those with oropharyngeal dysphagia and an unsafe swallow. Jesus and Stevenson recently emphasized the importance of optimizing nutrition and bone health in children with cerebral palsy, because the consequences of poor growth and malnutrition range from decreased bone density, muscle mass, and quality of life to impacts on intellectual quotient, behavior, attention, social participation, healthcare utilization, and health care costs.In this case, the patient has cerebral palsy, and is unable to chew regular food. Despite being on Megestrol, an appetite stimulant, the patient has documented progressive weight loss, and with a BMI of 16.7, he is underweight. The etiology of the patients weight loss is unclear from the documentation provided. The patient has radiographic evidence of osteopenia and will be at risk of fractures. The medical literature confirms the importance of maintaining good nutritional status for patients with cerebral palsy. Under these circumstances, the requested Ensure formula is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested nutritional product is medically necessary to treat 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: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested for morphine sulfate for treatment of her chronic pain. The physician reviewer found that the current medical evidence does not support the requested medication in this clinical setting.  This patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  Baron and McDonald reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  In this retrospective study, the majority of patients undergoing detoxification of high-dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia.  High-dose opiates may also cause adverse outcomes.  Ballantyne and Mao reported that prolonged use of high-dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects.  All told, the requested morphine sulfate is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the enrollees medical condition.  Credentials/Qualifications: The reviewer is board certified in anesthesiology 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: Urgent Care
Decision: Overturned

The parent of a 10-year-old female enrollee requested emergency services on an emergent basis for medical treatment of the enrollees medical condition.  Findings:  The physician reviewer found that a prudent layperson would have sought immediate medical attention on the date of service in question.  Although the patient was afebrile at the time of presentation to the ED, the patients parent reports that the patient had been experiencing a fever up to 103 degrees F as well as other acute symptoms (chills, cough, wheezing). These symptoms were of sufficient severity to cause a prudent layperson to believe the patients health could be in serious risk due to pneumonia, bronchospasm or other serious medical conditions. As such, the patients condition met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee requested authorization and coverage of individual dietary counseling for the treatment of diabetes.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old female enrollee requested authorization and coverage of bariatric surgery through the duodenal switch surgical procedure. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three  physician reviewers concluded that the requested surgery is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.