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 Neulasta Onpro kit (pegfilgrastim solution prefilled syringe kit 6 mg/0.6 mL) every 14 days, quantity of 12. Onpro is method of delivering pegfilgrastim that does not require the patient to return the following day for an injection. Pegfilgrastim is used for the prevention of neutropenic fever in patients receiving chemotherapy regimens with a risk of neutropenic fever of 20% or more. This patient is receiving dose dense Adriamycin and cyclophosphamide followed by paclitaxel. Per the National Comprehensive Cancer Network (NCCN) guidelines, the Adriamycin and cyclophosphamide portion of the regimen requires the use of pegfilgrastim, and patients receive up to four cycles (Becker, et al.). For paclitaxel, when administered in a dose dense fashion, then an additional four cycles would be performed with pegfilgrastim. Thus, this patient will likely require eight doses of Neulasta Onpro. Accordingly, the medical records support that Neulasta Onpro kit (pegfilgrastim solution prefilled syringe kit 6 mg/0.6 mL) every 14 days, quantity of eight (8) is medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the requested medication regimen is 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 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: An enrollee has requested reimbursement for residential treatment center level of care services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that The submitted documentation supports the medical necessity of the services at issue.  This patient had a very serious poly-addictive illness complicated by a co-occurring post-traumatic stress disorder and bipolarity.  She had been using substances for many years, and she had no significant periods of sobriety.  Prior to admission, the patient was consuming multiple substances on a daily basis and had overdosed twice on heroin to the point where naloxone rescue was necessary. Her extensive drug use dominated all domains of her existence and more than likely undermined her self-esteem and the developmental task of identity formation. She did not have the resiliency or an experiential foundation to draw upon in negotiating intrapsychic and interpersonal stressors.  Further, she had failed treatment in a less-restrictive setting during the episode of illness and was at high-risk for a poor outcome in the absence of appropriately matched care. It appears that the patient was engaged in active care throughout the admission, including modification of her psychotropic medication. Based on the longitudinal history and medical documentation, the patient had not consolidated the treatment gains necessary to succeed in a less restrictive setting and was likely to have promptly relapsed in the absence of residential programming had she been discharged. Both the services and setting were safe, appropriate and consistent with good practice, while the duration of treatment for a case of this severity aligned with community standards. All told, residential treatment center level of care services were medically necessary for the treatment of this patient. 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 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: A patient has requested authorization and coverage for Lyrica. The Health Plan has denied this request on the basis that the requested medication is not medically necessary for treatment of the enrollee's foot pain. Review of the submitted documentation supports the medical necessity of Lyrica in this clinical setting. The patient presents with traumatic neuropathy with motor involvement. The submitted records reveal the patient has EMG-confirmed peroneal neuropathy (sensorimotor). He has a history of treatment with gabapentin. Gabapentin is contraindicated in this patient as it caused mental confusion, which is a known side effect of the drug. As such, gabapentin is not appropriate for this patient due to well recognized neurologic side effects. Lyrica has been approved by the U.S. Food and Drug Administration for treatment of neuropathic pain. As such, the requested medication is medically reasonable and necessary for treatment of this patients medical condition.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 pain medicine and anesthesiology 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 two-year-old female enrollee has requested  for speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that the patient has an identified delay in expressive speech of approximately 61% and in comprehension of 32%. Speech therapy is indicated with any delay greater than 25% (Law, et al.). Improvements have been noted following speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty (Law, et al.). Treatment for language disorders is predicated primarily on the childs language profile and level of communication skills (Feldman and Messick). Children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman and Messick). Gallagher, et al. evaluated speech and language interventions for preschool children with specific language impairment and found statistically greater improvement with intensive direct speech therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee requested authorization and coverage of the medication provigil for the treatment of multiple sclerosis.  The health plan denied the enrollees request indicating that the requested medication 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 medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services provided.  Findings:  The physician reviewer found that The records provided for review do not document that this patient has demonstrated post-acute withdrawal symptoms. There is no evidence that she has been a danger to herself or others, and she has not been aggressive or violent. She has been cognitively intact and not gravely disabled. There have been no emotional, behavioral, cognitive, or impulsive symptoms that would warrant the residential treatment center (RTC) level of care.The member been medically and psychiatrically stable to the extent that she does not require the monitoring and supervision of a 24-hour facility to render the remainder of her care. Her medication management could have been performed in an ambulatory setting. There has been no documentation of mania, hallucinations, delusions, or any other significant symptom that would interfere with her care. She has been internally motivated and appears to be working the program. She has been cooperative and participating in all aspects of the treatment plan. She does require further treatment. However, the nature of her polysubstance use disorder has been highly recidivistic in nature, and there has been no evidence to suggest that further residential treatment would change the nature of this. The development and solidification of coping skills and her relapse prevention plan could have been continued at PHP level of care. Her social support was limited, however she showed the ability to reach out to her social support network in the 12 step group. The patient no longer required the structured environment of a RTC setting and could have been stepped down to an ambulatory level of care such as PHP in conjunction with community support and psychotropic medication management. All told, the RTC services provided were not and are not medically necessary for treatment of this patients behavioral health issues.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 sub-specialty 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient presents with clinical symptoms of hypogonadism, including fatigue and dysthymia. Records noted low testosterone levels. The patient has requested coverage for testosterone. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. Low testosterone can lead to complications of reduced libido/erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis/low bone mass, depressed mood and fatigue. Providers treat patients with hypogonadism when their testosterone level is less than 350 ng/dL. The recommended therapy for men with symptomatic testosterone deficiency is to induce and maintain secondary sex characteristics and correct symptoms of hypogonadism. Clinical guidelines recommend making a diagnosis of hypogonadism in men with signs and symptoms consistent with testosterone deficiency and unequivocally and consistently low serum testosterone concentrations, drawn while fasting in the early morning. This patients laboratory test was obtained in the afternoon rather than in the morning, as recommended by clinical guidelines. The medical evidence does not support the requested medication in this clinical setting. Therefore, the requested testosterone is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested service 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 with a sub-specialty 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for proton beam radiation therapy (PBRT). Standard radiation is delivered with a linear accelerator (LINAC), which delivers photon therapy, while protons are generated from a cyclotron. The difference between proton and photon irradiation is that there is a Bragg peak with protons, which stop abruptly in the tissue, so there is less exit dose through normal tissue. The use of proton therapy is an accepted radiation technology, which has proven efficacy and tolerability in specific clinical settings. However, there is a lack of compelling data to suggest that proton therapy is superior to or more beneficial than standard therapies including intensity modulated radiation therapy (IMRT) for treatment of prostate cancer. Therefore, the PBRT provided to this patient was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the PBRT provided to this patient was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were 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:  One reviewer is board certified in radiation oncology and is actively practicing. One Reviewer is board certified in radiation oncology and is actively practicing.  One Reviewer is board certified in radiation oncology and is 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 58-year-old female enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) for evaluation of the enrollees left knee pain. Findings:  The physician reviewer found that the requested MRI is the appropriate method for the evaluation of this patients chronic knee pain status post fall. MRI is the current gold standard for the assessment of soft tissue, chondral, and bony pathologies of the knee joint. In this case, the patient has chronic knee pain with recurrent effusions. Physical examination shows a joint effusion and medial joint line tenderness. McMurray is plus or minus and there is no instability. X-rays have been negative for bony trauma and do not show osteoarthritis. As such, additional diagnostic testing is necessary to evaluate from the viewpoint of arthroscopy. The MRI scan is accurate for the diagnosing meniscal tears and remains the gold standard. Consistent with the current medical literature, the requested MRI is medically necessary for further evaluation of this patients knee pain. Final Result: The reviewer determined that the requested diagnostic procedure 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 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: A female enrollee has requested authorization and coverage for bilateral total hip arthroplasty. Total hip arthroplasty is the final and definitive treatment for patients with severe hip arthrosis which remains painful and limiting despite conservative treatment. In this case, there is limited documentation of prior conservative treatments that have been exhausted. In addition, the imaging studies forwarded for review do not support a diagnosis of severe bilateral hip arthrosis. Specifically, the radiology report notes that the patients hip joint cartilage spaces are preserved. Further, the patient is young and would be at statistically increased risk of eventual failure of the artificial joints and need for further surgery. Overall, the medical records provided for review do not support the need for this request for bilateral total hip arthroplasty in this patient. Therefore, the requested bilateral total hip arthroplasty is not medically necessary for treatment of this patients hip 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly psychology visits and somatic experience therapy. The records provided for review indicate that this patients weekly psychology sessions have consisted of cognitive behavioral therapy (CBT) processing therapy. Reports show strong evidence to support the efficacy of prolonged cognitive therapy for the treatment of patients with PTSD. Reports further state that there is a moderate strength of evidence for CBT, CBT processing therapy, narrative exposure therapy, and cognitive therapy. Regarding the frequency of visits, it is generally established that in order to be effective, psychotherapy is conducted on a weekly basis. Given this patients presentation and prior response to weekly psychotherapy, the requested weekly psychology visits are medically necessary. However, the peer-reviewed medical literature has not demonstrated somatic experience therapy to be effective for patients with PTSD. Researches conducted a study on 63 patients to evaluate somatic experiencing therapy. Researchers found that somatic experience therapy may be an effective therapy method for PTSD, but that further research is needed to understand which patients would benefit most from this treatment modality. Given these findings, the requested somatic experience therapy is not medically necessary for treatment of this patient. All told, the requested weekly psychology visits are medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the requested services is 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 parent of an enrollee has requested authorization and coverage for the Synagis vaccine. At issue in this case is whether the requested Synagis vaccine is medically necessary for treatment of the enrollees medical condition. In 2014, the American Academy of Pediatrics issued new guidelines for the administration of Synagis for respiratory syncytial virus (RSV) prophylaxis based on review of current peer-reviewed literature related to burden of RSV in infants and children with emphasis on those at highest risk of severe disease. The following groups of patients are considered at highest risk, with recommendations for administration of Synagis: infants born before 29 weeks gestation younger than 12 months of age at the start of RSV season; infants with chronic lung disease of prematurity born before 32 weeks gestation during the first year of life, with some consideration during the second year of life if continued medical support is necessary; infants 12 months of age or younger with hemodynamically significant congenital heart disease (excluding those with lesions adequately corrected by surgery unless medication is necessary for ongoing congestive heart failure); consideration for infants 12 months of age or younger with anatomic pulmonary abnormalities or neuromuscular disorders that have difficulty clearing secretions; consideration for infants less than 24 months of age that are profoundly immunocompromised; and consideration for infants with Down syndrome or cystic fibrosis that have evidence of other risk factors such as chronic lung disease or congenital heart disease. Researcher found, the current literature supports and substantiates the changes in administration guidelines made by the American Academy of Pediatrics. Based on the current American Academy of Pediatrics guidelines, Synagis is not medically necessary for this patient for the 2018-19 RSV season.Final Result: The reviewer determined that the requested medication 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 subspecialty certification in pediatric critical care 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

A 47-year-old male enrollee has requested for Avastin in combination with Temodar for treatment of his anaplastic astrocytoma. Findings:  The physician reviewer found that there are no established phase III trials because of the rarity of the disease. Expert guidelines and compendium listing have relied on phase II studies. The studies with the combination of irinotecan and bevacizumab are extremely new and thus have not been evaluated for listing by the compendium.