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

The patient has requested authorization and coverage for Uceris (budesonide rectal foam 2 mg twice daily for two weeks, then daily). This patient has failed oral 5-aminosalicylate therapy and rectal corticosteroid suppositories. Guidelines from the American Gastroenterological Association (AGA) state, In patients with mildmoderate ulcerative proctosigmoiditis who choose rectal therapy over oral therapy, the AGA suggests using mesalamine enemas rather than rectal corticosteroids. Marshall and colleagues noted, Rectal 5-aminosalicylates (5-ASA) should be considered a first-line therapy for patients with mild to moderately active distal ulcerative colitis. In this case, there is no documented attempt of rectal 5-aminosalicylate therapy. As the patient has not attempted rectal 5-aminosalicylate therapy, the use of rectal corticosteroids is not supported by guidelines for the treatment of ulcerative colitis. Therefore, Uceris (budesonide rectal foam (2 mg) twice a day for two weeks, then daily) is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of this patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi for 12 weeks for treatment of her 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.  Per the guidelines, genotype 2 patients should be treated with daily Sovaldi and weight-based ribavirin for 12 weeks.  These guideline recommendations are based on multiple randomized clinical trials.  All told, Sovaldi for 12 weeks is medically indicated for the 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 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: Upheld

A 45-year-old female enrollee has requested vagus nerve stimulation (VNS) therapy for treatment of her bipolar disorder and depression. Findings:  Two physician reviewers found that VNS remains experimental at this time and is not likely to be effective in this clinical setting. Furthermore, based on the records provided, it does not appear the patient has been treated with electroconvulsive therapy or MAOIs. Thus, there are alternative standard therapies available that are likely to be more efficacious than VNS therapy, which remains clinically unproven.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested for a referral to an otolaryngologist for treatment of her jaw pain. Findings:  The physician reviewer found that there is no evidence demonstrating that a referral to an otolaryngologist is clinically indicated for evaluation and management of this patients jaw pain/TMJ disorder.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment center services.On admission, the patient indicated that anxiety was an issue she had struggled with for years. She was noted to be calm and cooperative in treatment, without any oppositional behaviors. Her grades in school were good, and her activities of daily living appeared intact. She denied suicidal ideation.  During the disputed timeframe, the patient demonstrated cooperative behavior. She followed treatment programming as she was instructed. The patient did not display aggression towards peers or staff during the disputed timeframe. Her family was involved with treatment.The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 1. The patient was not actively or passively suicidal. With regards to functional status, the records support a score of 2. The patient has had some issues with level of functioning due to mental illness and substance use, but overall showed appropriate daily functioning while in treatment. In terms of comorbidity, the records support a score of 2. The patient did not have active medical problems. The records documented cannabis use. With regards to level of stress of the recovery environment, the records support a score of 2. There was no indication of an unsafe home environment. In terms of level of support of the recovery environment, the records support a score of 2. The patients parents were involved in treatment on a regular basis. With regards to resiliency and treatment history, the records support a score of 2. The patient demonstrated cooperative behavior with symptom resolution in the residential treatment center. In terms of acceptance and engagement of the patient, the records support a score of 2. The patient actively participated in therapy on admission. With regards to acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Thus, the patient had a composite score of 15. This score correlates with outpatient services. Therefore, residential treatment center services were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a nineteen-month-old male enrollee has requested for array comparative genomic hybridization testing for evaluation of the enrollees global developmental delay. Findings:  Two physician reviewers found that the major malformation is macrocephaly caused by polygyria and an increase in the amount of gray matter. This is the type of constellation in which the yield of testing to examine chromosomal fine structure would be expected to have a substantial diagnostic yield. The requested testing had its genesis in the genetic analysis of cancers, where it has been very useful in establishing the genetic nature of a variety of solid tumors.  It has been increasingly applied to patients with developmental delay in whom other methodologies have not yielded a diagnosis. In a series of such patients with global developmental delay, an etiologic yield was 6.4%, but half of those had minor malformations.  Furthermore, none of those had more than two malformations, while this patient has more than three.  In a study reported by Engels and colleagues examining patients with abnormal neurological imaging, the yield of etiological information from this testing was twice that of those without this testing.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee is requesting a second cochlear implant for the treatment of her severe bilateral sensorineural hearing loss. Findings:  The physician reviewer found that there is a lack of scientific evidence to support that medical necessity and benefit outweigh the risk of the second implant to the opposite ear.  Available studies are largely small and without strict scientific methodology. As such, there is not enough documented evidence to support that a second cochlear implant is medically indicated. Cochlear implantation in both ears is unproven for hearing loss in adults. Clinical evidence of safety and effectiveness for cochlear implantation in both ears is lacking at this time.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Three physician reviewers found that in this patients case, the services at issue were likely to have been superior over other available modalities.  The current medical evidence supports the services at issue in this clinical setting.  The data demonstrates advantage when breast tomosynthesis is used.  The addition of breast tomosynthesis to screening mammogram has been associated with an increased rate of detection of small cancers, especially in patients with dense or heterogeneously dense breast tissue.  All told, breast tomosynthesis was likely to have been of greater benefit than other methods of evaluation.  Final Result:  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.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a power wheelchair for treatment of the enrollees lower extremity bilateral paralysis. Findings:  The physician reviewer found that colleagues state that The benefits of power-mobility devices are reported to include improved quality of life, an increased sense of freedom and improved self-esteem. Power mobility can benefit specific individuals. Determining who will benefit is a matter of clinical judgement more than adherence to criteria defined by the medical literature. In this case, the patient has utilized a manual wheelchair for many years. He has subjective complaints of arm pain and fatigue but on evaluation he uses a manual wheelchair without difficulty. In addition, evaluation found multiple barriers to implementation of a PWC including lack of transport and lack of ingress/egress to his abode. The patient has a personal mobility deficit that has been effectively treated with a manual wheelchair. A PWC is not medically necessary due to the effectiveness of the manual wheelchair and multiple barriers to usage of a power wheelchair. Accordingly, the request for PWC has not been established as medically necessary for treatment of the patients lower extremity bilateral paralysis. 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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

The parent of an eight-year-old male has requested applied behavioral analysis (ABA) therapy services for treatment of his autism. Findings:  Three physician reviewers found that ABA therapy has been shown to be effective in treating behaviors associated with autism spectrum disorders (Dawson, et al.; Rogers, et al.; and Warren, et al.). The scientific literature supports the use of ABA. Treatments based on operant principles of learning are more effective for reducing problem behavior than alternative treatments. The ABA services at issue were and are likely to be more efficacious than any other therapy for treatment of the patients autism.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for the Nucca method for treatment of the enrollees brachioradial pruritus. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services at issue. There is a lack of peer-reviewed literature supporting the utility of the Nucca method for the treatment of the patients medical condition. In addition, there is a lack of evidence-based guidelines demonstrating that the Nucca method is more effective than other chiropractic manipulation techniques. In this case, the patient reports improvement with the Nucca method, however the relief is temporary. There is a lack of evidence-based guidelines supporting ongoing maintenance care in this clinical setting. Based on the lack of support in the peer-reviewed literature, the Nucca method was not and is not supported as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in chiropractic care 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 authorization and coverage for phrenic nerve repair. Findings: Two of the three physician reviewers found that there is a lack of support for the requested services in this clinical setting. The requested services may be appropriate for patients with specific indications, such as phrenic nerve injury after cervical trauma, following thoracic surgery, following cardiac surgery or following central line insertion and injury. Further indications include vascular compression in the neck or mediastinal abnormality causing compression or injury to the phrenic nerve. In this patients case, the records do not document these indications for phrenic nerve repair. In sum, the requested phrenic nerve repair is not likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the requested services are 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: All physician reviewers are board certified in thoracic and cardiac surgery 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

A 62-year-old female enrollee has requested Zegerid 40 mg for the treatment of her gastroesophageal reflux disease (GERD). Findings:  The physician reviewer found that the available literature does not support that any one proton pump inhibitor (PPI) is superior to the others. However, it is clear that some patients respond better to one agent than to others, although the reasons for this are not clear. In the case of this patient, she has tried and failed the plan's alternatives in the past and therefore further trials with these medications are likely to also be unsuccessful. The patient has intermittent symptoms of GERD which have been well controlled on Zegerid and she requires the use of an NSAID (non-steroid anti-inflammatory) for another condition. Therefore, the continued use of the Zegerid is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for 8 weeks. These guideline recommendations are based on multiple randomized clinical trials. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 16-year-old female status post a motor scooter accident in 2001 in which she sustained ligament and tendon damage to the wrist requiring repair. The patient sustained a humeral fracture, which was undiagnosed. She has been treated with improvement in muscle strength, but without much improvement in symptomatology. The patients orthopedic surgeon recommended a referral to a shoulder specialist orthopedic surgeon for consideration of surgery to correct hyperlaxity and impingement of the shoulder. The patients mother has requested authorization for additional physical therapy visits prior to referral to a shoulder specialist to see if further therapy will resolve the issue.At issue is whether additional physical therapy is medically necessary for treatment of the patients condition. The Health Plan has authorized four visits with the possibility of further sessions if progress is documented. Given the documentation by the patients physical therapist and orthopedic surgeon, which indicates that little improvement in symptoms has occurred with the initial six physical therapy sessions, it is probable that further sessions will not be of great benefit in reducing the patients symptoms. This is particularly true in light of the patients compliance with a home-exercise program. The Health Plans authorization of four additional physical therapy visits followed by reevaluation is medically reasonable and appropriate. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old male enrollee requested authorization and coverage of a referral to a pain management physician for the treatment of lower back pain.  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: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested lap band surgery for the treatment of her obesity. Findings:  The physician reviewer found that the NIH (National Institutes of Health) guidelines for obesity surgery that are recognized by all of the major specialty societies are that the surgery is indicated for the treatment of morbid obesity in patients with a BMI greater than 40; or in patients with a BMI between 35 and 40 if they also have co-morbid conditions such as hypertension, type 2 diabetes, sleep apnea, etc. This patient is not morbidly obese. The patient has a calculated BMI of 30. This puts her in the `obese` category, but not in the morbidly obese category. In any case, even at her current weight, bariatric surgery is not medically necessary for the treatment of her obesity.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gazyva, cycles 7-12.  Findings:  The physician reviewer found that Stage at presentation and certain biomarkers in CLL affect an individual patients clinical course. Imbruvica is a tyrosine kinase inhibitor with some specificity toward the Bruton tyrosine kinase. The Bruton tyrosine kinase-signaling pathway is important for normal B-cell function and B-cell neoplasms. Thus, Bruton tyrosine kinase inhibition is a reasonable treatment choice for patients with diverse B-cell malignancies. Imbruvica has been tested against CLL in phase Ib-II clinical trials (Byrd, et al). The authors found that Imbruvica induced durable remissions in patients with relapsed and refractory CLL with minimal side effects. Six cycles of Imbruvica in combination with anti-CD20 immunotherapy resulted in increased progression free survival compared to chlorambucil and Gazyva in previously untreated CLL patients (Moreno, et al). The U.S. Food and Drug Administration (FDA) approval of Gazyva does not include a provision for additional cycles in the treatment of CLL. This patient has CLL treated with six cycles of Gazyva. Based on the current medical literature, there is a lack of support for extending therapy beyond six cycles in this clinical setting. Therefore, Gazyva, cycles 7-12 is not medically necessary for treatment of this patient. 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 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.