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

The parent of a 17-year-old female enrollee has requested psychiatric acute inpatient services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the psychiatric acute inpatient services were not medically necessary for treatment of the patients behavioral health condition. According to the psychiatric evaluation, the patient was not having suicidal, self-harm or aggressive ideations. Her thought process was linear and her cognition was unimpaired. Her mood was euthymic and her affect was appropriate. From the time of admission, she had consistently denied suicidal ideation. She was adherent with her medication. She did not pose any imminent threat to self or others or evidence grave disability. She was never psychotic, delusional or cognitively impaired. She had four behavioral/cognitive episodes that resulted with incident reports, but the patient had no persistent distress consistent with a prolonged acute psychiatric syndrome.  Additionally, the treatment plans targeted tasks related to emotional regulation, self-esteem, accountability, acceptance of feedback, building and maintaining relationships, and impulsive behaviors, among others. Such themes are commonly addressed in settings other than the acute inpatient venue. In sum, a less restrictive treatment setting would have been safe, appropriate and reasonably expected to improve the patients condition. Considering the case in its entirety and the relevant peer reviewed literature, the psychiatric acute inpatient services were not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for laboratory services. Antiphospholipid antibody syndrome is a known etiology associated with cerebral infarction and transient ischemic attacks (TIA). Patients with this syndrome are at risk of hypercoagulability and future events (Bala, et al.). In this case, the patient presented with symptoms that frequently occur with TIA. The presence of positive laboratory testing would have helped guide the patients management. Although not essential in every TIA work-up, this testing can be useful to the patient if antibodies are discovered, as it will help guide therapy (Mustonen, et al.). Therefore, the laboratory services were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Findings: The services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  One reviewer is board certified in neurology and is actively practicing. One Reviewer is board certified in neurology with subspecialty certification in neuromuscular medicine and is actively practicing.  One Reviewer is board certified in neurology 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: An enrollee has requested reimbursement for a Synvisc-One injection and related services and prospective authorization and coverage for Euflexxa/Synvisc injection services for treatment of the enrollees knee pain. Findings:  The physician reviewer found that there is support for a portion of the services at issue in this clinical setting. This patient presents with chronic right knee pain. Clinical examination findings are consistent with the diagnosis of right knee osteoarthritis. The patient reported that reasonable conservative treatment, including medications, activity modification, and exercise have failed to provide adequate symptom relief. It was noted that prior viscosupplementation injections had provided significant sustained relief for six months. The patient underwent viscosupplementation with six months of relief, and repeat injections. Evidence based medical peer reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery and may be reasonable when there is improvement in symptoms for six months or more. Given the previous response to the Synvisc-One injection, a previous injection was medically indicated. However, there is insufficient documentation provided to support the medical necessity of current or future viscosupplementation injections for this patient. There is no discussion regarding the efficacy of a Synvisc-One injection relative to the duration of relief to support a repeat injection currently and in the future. Therefore, a previous Synvisc-One injection and related services were medically necessary for treatment of this patients knee pain but the requested future viscosupplementation injections are not medically necessary. 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 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

The patient is a 58-year-old woman with frequent migraine-like headaches. She was previously treated with Topamax 25mg, as she experienced paresthesia at 50mg. In addition, she has received Elavil 30mg with some improvement. There is no documentation of a trial of Depakote or beta-blockers in the submitted records. The patient takes triptans, which help relieve the headaches. She has received a trial of Botox in the past. Her provider has recommended additional Botox injections for migraine relief. The Health Plan has denied authorization for the proposed therapy on the basis it is not medically necessary.Review of the submitted clinical records indicates the patient has episodic migraine though it is not documented how many days per month she experiences headaches. The patient had some response to low doses of Elavil 30mg and her provider indicated she would likely respond to higher doses, but there are no records to indicate higher doses were tried. The patient may benefit from a higher dose of Topamax. The paresthesia she experienced at 50mg is typical and usually responds to KCI supplementation. Furthermore, the patient has not been tried on beta-blockers or Depakote, which may be helpful.Based upon the information provided, the patient has not exhausted standard medications for the treatment of migraines. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old male enrollee has requested SPECT (DaTscan) for evaluation of his tremors. Findings:  Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  The diagnoses of Parkinsons disease and essential tremor are made on clinical grounds.  SPECT studies are not necessary to make the diagnosis of either Parkinsons disease or essential tremor and have not been proven to substantially improve a patients medical condition.  Therefore, the SPECT (DaTscan) performed on the specified date was not likely to have been of greater benefit than other available modalities for evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Rydapt for treatment of the enrollees acute myeloid leukemia. Findings:  The physician reviewer found that there is support in the literature for the requested medication in this clinical setting. Acute myelogenous leukemia is categorized into three risk types: low, intermediate, and high. The stratification is based on cytogenetics. Within this group, clinical outcomes still appear heterogeneous. Therefore, other molecular markers have been identified to enable further prognostication of these sub-types. The patient in this case has a FLT3 TKD mutation. This mutation has been associated with shorter remission durations and decreased overall survival outcomes. The use of Rydapt has demonstrated clinical efficacy and benefit in this AML sub-type. The National Comprehensive Cancer Network guidelines strongly recommend clinical trials as standard therapy for patients with poor prognostic features, which include FLT3 mutations, in the setting of otherwise NK-AML (normal cytogenetics), high white blood cell at diagnosis, or two cycles of induction therapy needed to achieve complete remission. Allogeneic hematopoietic cell transplantation with matched donor is considered standard for those with poor cytogenetics or molecular abnormalities. The submitted documentation indicates that this patient has the molecular characteristics that would make her a candidate for Rydapt, and she meets the U.S. Food and Drug Administration clinical criteria for its use.  For the reasons noted above, Rydapt is medically 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 internal medicine with sub-specialty certification in medical 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: Upheld

The enrollee is requesting authorization and coverage for a power mobility scooter. The enrollee has lower back pain due to degenerative disc disease (DDD), inability to walk, and morbid obesity. She was evaluated due to complaints of pain in her left toes and complaints of redness, swelling, burning, and occasional purple discoloration of her toes. Physical therapy assessment for the requested mobility scooter indicates the powered equipment (mobility scooter) is not medically necessary but instead a four-wheeled walker with a seat was recommended to help the patient keep ambulating and take rest breaks as needed; and considered the heavy duty four wheeled walker with a seat is medically necessary to increase her safety and decrease her fall risk due to altered balance. According to the medical literature, studies go against recommending motor scooters prematurely because of the risk of further physical de-conditioning, leading to permanent disability and increased cardiovascular risk.  Interventions, such as scooters, that improve self-perceived quality of life, can have detrimental long-term effects by increasing cardiovascular risk, particularly insulin resistance. Risks should be carefully weighed before approving their use, as well as ensure healthy levels of activity afterward. There is insufficient evidence in the record supporting the patient has mobility deficits which impair her participation in mobility-related activities of daily living. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in physical medicine and rehabilitation 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old male enrollee has requested circumcision for treatment of the enrollees phimosis. Findings:  The physician reviewer found that this patient presented with paraphimosis, and after reduction of that paraphimosis, now has irritation and phimosis. Options include surgical treatment via circumcision or conservative therapy via application of topical steroid cream for six weeks and watchful waiting. A trial of topical steroids would require the proper and regular use of the medication and is in some cases likely to fail as it is too user-dependent. In addition, in the event of such a trial and failure, circumcision would then be performed as it is the definitive therapy for paraphimosis.This patient has a proven history of phimosis after paraphimosis, and therefore circumcision is indicated and medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The father of a 15-year-old male enrollee requested authorization and coverage of inpatient residential services for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees developmental disorder.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested services are medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Entyvio infusions every four weeks. Entyvio has been demonstrated to be safe and effective for the treatment of patients with moderate to severe ulcerative colitis (Park and Jeen). In addition, the American College of Gastroenterology (ACG) guidelines support Entyvio as a primary therapy for moderate to severe ulcerative colitis by (Rubin, et al.). Dose intensification of Entyvio with infusion more frequently than every eight weeks has been assessed in high-quality clinical trials. The randomized placebo-controlled GEMINI I and II trials demonstrated support for the U.S. Food and Drug Administration (FDA) approval of Entyvio. The studies found that patients who had not achieved remission by week six benefitted by Entyvio every four weeks rather than every eight weeks (Feagan, et al.; Sandborn, et al.). The GEMINI long-term safety study showed that a significant number of patients with ulcerative colitis who had lost response to Entyvio every eight weeks regained response with four-week dosing (Loftus, et al.). The records document that this patient with ulcerative colitis attained remission on Entyvio 300 mg every four weeks. If the patients Entyvio dose is decreased or Entyvio is discontinued and changed to an alternative medication, the patient is at risk for serious complications of ulcerative colitis. For these reasons, the requested Entyvio infusions every four weeks is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in 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 38-year-old female enrollee has requested a hydrogen breath test for the treatment of her gastrointestinal symptoms. Findings:  The physician reviewer found that the utility and specificity of hydrogen breath testing in patients with small intestinal bacterial overgrowth (SIBO) is not a settled issue among the gastroenterology community (Chey). The usefulness of a positive breath test in SIBO with diarrhea may have the same significance as a positive breath test in an individual with abdominal bloating and chronic constipation (Chey). Furthermore, in this case, there is no documentation which supports how medical therapy of the patients functional symptoms will be changed by a breath test result that is either positive or negative. The requesting physician has not stated that a negative breath test would mean that he would elect to not treat this patient with antibiotics for presumed small intestinal bacterial overgrowth or that he would use a negative test to explore other diagnostic possibilities for her symptoms. As such, there is inadequate evidence to support the use of a hydrogen breath test in this setting.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 10-year-old male enrollee has requested speech and language services and small group social skills coaching program to develop positive social skills through play for treatment of the enrollees autism. Findings:  The physician reviewer found that the requested speech and language services are not medically necessary for treatment of the patients medical condition. The medical literature cited above supports the effectiveness of speech and language services in autistic children; however, this patients expressive and receptive speech has tested well into the normal range. This patient is not deficit in the generation or understanding of speech, but rather in being able to appropriately alter his inflection, tone, volume and appropriateness to varying social circumstances. Generally, this is a learned response from ongoing and varying social exposures and it is unlikely that this can be improved in formal speech/language therapy sessions. The requested small group social skills coaching program to develop positive social skills through play is not medically necessary for treatment of the patients medical condition. Although the patient does have deficits in social communication, he is minimally impaired with near to normal intellect and the record indicates that he has achieved maximum benefit with his prior therapies. This patient has spent several years in a very small group and the value of this small group has been effective, but he needs exposure to increasingly larger groups. Reichow and colleagues point out that socialization is extremely important to an autistic child as he/she approaches the age of a teenager. However, the authors emphasizes that the socialization tends to come from increasing larger groups, such as school classrooms and mingling with larger groups.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for intravenous (IV) Gammagard for home use (1.4 gm/kg divided over three days initially, followed by 0.8 gm/kg divided over two days every four weeks). Standard treatment of small fiber neuropathy is dependent on the underlying etiology as well as treatment of associated neuropathic pain, which can include several different classes of medications. IVIG is a first-line treatment for immune-mediated neuropathies such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. The studies above note some benefit of IVIG in patients with small fiber neuropathy, though these patients have serologic evidence of autoimmunity. In this case, the patient has a clinical picture consistent with a small fiber neuropathy, a possible underlying autoimmune condition. However, the records do not include documentation of blood test markers associated with autoimmunity or inflammation. Therefore, IV Gammagard for home use (1.4 gm/kg divided over three days initially, followed by 0.8 gm/kg divided over two days every four weeks) is not likely to be more beneficial for treatment of the patients small fiber neuropathy than any available standard therapy. Final Result: The reviewers determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in neurology 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: Upheld

The patient is a 47-year-old woman with a body mass index (BMI) of 36. She has comorbid conditions including gastroesophageal reflux disease and sleep apnea. She has requested authorization for gastric bypass surgery. The Health Plan has denied the patients request.With a BMI of 36 and her comorbid conditions, the patient does not meet nationally accepted medical necessity criteria for consideration of weight loss surgery. There is potential that further attempts at conservative weight loss will be successful. Furthermore, as the patient has the potential for further weight loss through conservative means, the risks of weight loss surgery do not outweigh the potential benefits of the procedure. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 65-year-old female enrollee has requested Lunesta for the treatment of her insomnia. Findings:  The physician reviewer found that Lunesta was and is medically appropriate for this patient. The patient experienced significant side effects on Ambien. Lunesta has been safe and effective for this patient. Additionally, improved safety of Ambien versus Lunesta in patients over 65 has not been demonstrated in peer-reviewed scientific studies. As such, it is medically reasonable and appropriate for this patient to continue taking Lunesta for treatment of her insomnia.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 27-year-old female with a long history of back, neck, and shoulder pain. She has been evaluated and treated by her primary care physician, her chiropractor, and her physical therapist. The patients providers believe the patients large breasts are contributing to her symptoms. She was referred to a plastic surgeon for evaluation. The plastic surgeon concurred with the patients previous examiners and recommended the patient undergo breast reduction surgery. The Health Plan indicates a breast reduction is not medically necessary for treatment of the patients medical condition.The patient is 64 inches tall and weighs 135 to 140 pounds. She wears a size 32 DDD bra. The submitted photographs demonstrate the diagnosed mammary hypertrophy as well as shoulder grooving and hyperpigmentation secondary to heavy breasts. The photographs and documentation from the patients primary care physician, chiropractor, and plastic surgeon provide medical justification for the requested procedure. Breast reduction surgery is medically appropriate and is likely to alleviate the patients symptoms. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.