Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

A 29-year-old female enrollee has requested authorization and coverage for intravenous immunoglobulin (IVIG) therapy. The health plan has denied this request indicating that IVIG is considered investigational for treatment of the enrollees recurrent pregnancy loss.All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the health plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an eight-year-old male enrollee has requested speech therapy for the treatment of the enrollees speech and language deficits. Findings:  The physician reviewer found that the purpose of therapy for children with Aspergers Syndrome (AS) is to improve social functioning. The primary therapies for AS include social skills training, cognitive behavioral therapy, occupational therapy and/or physical therapy if there is poor motor coordination, medications if there are co-existing anxiety, depression or attention issues and specialized speech and language therapy to help children with difficulties in the pragmatics of speech. Instruction in the give-and-take of normal conversation along with parent training and support are common. This patient has been mainstreamed and attends a general education classroom. He has achieved all of the goals and objectives of his IEP with the school services provided. There is no evidence that the intensive in-home speech therapy, now in its third year, is clinically essential or is providing a health benefit beyond that achieved in the school setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for referral to see an orthopedic specialist for evaluation of the enrollees joint pain. Findings:  The physician reviewer found that current evidence based medical guidelines state that initial management of pain includes referral to orthopedic specialists for evaluation of pain when there are indications for fracture or dislocation, infection, inflammation, or progressive neurologic or vascular deficit. Referral for orthopedic consultation is also supported if the patient has failed non-surgical treatments. The need for a clinical office visit with a health care provider is individualized based upon a review of the patient concerns, signs and symptoms, clinical stability, and reasonable physician judgment.  This patient presented with a complaint of a lot of joint pain.  However, there was no documentation by the primary provider of a specific history of injury, specific subjective complaints, or objective findings to support the medical necessity of an orthopedic referral. A diagnosis of pain in the joint of the hand was documented. The patient has additionally reported a fall with injury to her left shoulder, elbow and right knee. There was no record that her primary care provider has examined these body parts or that an initial conservative management has been attempted. There was no compelling rationale in the submitted documentation to support the medical necessity of a referral to an orthopedic specialist when initial evaluation and management of these complaints is within the armamentarium of the primary care provider. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lyrica for treatment of the enrollees multiple sclerosis (MS). Findings:  The physician reviewer found that Lyrica has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of post herpetic neuralgia, diabetic neuropathy, fibromyalgia, other neuropathic pains syndromes and epilepsy. It has been extensively utilized for both central and peripheral neuropathic pain, and the medical literature is replete with studies showing its effectiveness. Lyrica is recommended for a variety of neuropathic pain syndromes in various reviews of chronic neuropathic pain. Lyrica has been recommended as a first-line agent in a meta-analysis concerning treatment of chronic neuropathic pain. Given that this patient has reportedly tried treatment with nortriptyline, gabapentin, tramadol, and amitriptyline and the recognized utility of Lyrica for treatment of neuropathic pain, Lyrica is clinically indicated for this patient. Moreover, prior authorization and step therapy policies that restrict the use of Lyrica may lead to a higher utilization of opiates. 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 40 hours per week of one-on-one applied behavioral analysis (ABA) therapy. Findings:  The physician reviewer found that the medical necessity of ABA services is supported in the peer-reviewed literature as the standard of care for the treatment of individuals with autism. There is sufficient evidence supporting the correlation between treatment outcomes and ABA treatment intensity. In this case, the patient continues to demonstrate impairment in several areas including tantrums and self-injury and he has not met the majority of his ABA treatment goals. The Health Plan has been authorized for 29 hours per week of direct one-to-one ABA services, which is on the low end of what is typically recommended for optimal response. The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30-40 hours of treatment per week. Given the patients tantrum and self-injurious behaviors, the request for 40 hours per week of ABA has been established as medically necessary in this clinical setting. Final Result: The reviewers determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for trastuzumab (Herceptin) (CPT code J9355) and chemotherapy administration (CPT code 96413). Findings:  The physician reviewer found that this patient has GEJ adenocarcinoma with regional metastases and progression on standard multi-agent chemotherapy. Her tumor was submitted for the Foundation One mutational analyses which revealed multiple mutations, most notably ERBB3 amplification (HER3), epidermal growth factor receptor (EGFR) amplification, among others. ERBB3 is a transmembrane protein with limited kinase activity on its own. ERBB3 requires heterodimerization with ERBB2 (HER2). Recently, it has become important to identify mutations that may be amenable to targeted therapy. A study of 86 patients where the progression-free survival on regimen selected by molecular profiling was compared to progression-free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. Given the extensive clinical experience in gastric cancer, Herceptin is an appropriate next line of therapy in this clinical setting. Given the findings on this patients Foundation One mutational analyses and the current medical literature, the requested trastuzumab (Herceptin) (CPT code J9355) and chemotherapy administration (CPT code 96413) is supported as medically necessary for treatment of this patients GEJ invasive adenocarcinoma. 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 medical oncology with sub-specialty certification in 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: Upheld

 The parent of a 17-year-old male enrollee requested surgery to realign the spinal cord for medical treatment of his spinal cord injury. Findings:  The physician reviewer found that this patient has sustained devastating body injuries and remains seriously ill. Despite consideration for surgery, the patient is not a candidate for surgery because of his co-morbidities including pulmonary, sepsis, fever, and skin breakdown at multiple sites. The patients thoracolumbar injury severity score (TLISS) is 4 given the burst compression fracture, ASIA A spinal cord injury, and intact posterior elements. In the medical literature, a TLISS score of 4 places the patient in the non-operative category (Ellenbogen, et al; Vaccaro; et al). In addition, Stannard and colleagues noted that indications for surgery are based on the stability of the injured spine. This patients records document spinal stability. Further, the patients posterior elements are not injured, thus making this a stable fracture. All told, the requested surgery to realign the spinal cord is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee has requested Synvisc injections for treatment of her knee pain.  Findings:  The physician reviewer found that viscosupplementation for treatment of symptomatic osteoarthritis has been shown to be of value in appropriate patients, with evidence of safety and efficacy. It is most effective in cases with less evidence of severity and with mild or no effusion, and is less effective in cases with moderate to severe disease activity. It is also suitable for patients for whom other approaches are contraindicated or have failed. The Health Plan appropriately requires trial periods for the use of NSAID medications prior to injection.  In this case, there is no documentation in the medical record of the use of NSAID medications, nor the response to them.  There is no documentation of the rationale for the selection of Synvisc for injection rather than the preferred medications.  All told, the submitted documentation fails to establish the medical necessity of the services at issue.  Thus, Synvisc injections provided during the said timeframe were not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient was diagnosed with Beckwith-Wiedemann syndrome, macroglossia, obstructive sleep apnea, and tracheostomy dependence. The provider noted that the patient underwent a drug induced sleep endoscopy that revealed a tongue- based obstruction. Subsequently, a tracheostomy was performed. Physical examination findings noted that the patient had very full cheeks, and that his tongue fit behind and between his teeth at rest. The patient's tonsils were rated as two plus. The records noted that tonsillectomy and adenoidectomy with glossectomy were recommended by the patients in-network provider. In a letter, the patients parent reported that she desired for surgery to be performed by an out-of-network provider due to his surgical experience and patient outcomes. The patients parents also requested an adenoidectomy/tonsillectomy not be performed. The patients parent has requested authorization and coverage for an anterior wedge reduction with a W-shaped cut without a tonsillectomy and adenoidectomy. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether an anterior wedge reduction with a W-shaped cut without a tonsillectomy and adenoidectomy is medically necessary for the treatment of the patients medical condition. BeckwithWiedemann syndrome is a rare congenital overgrowth disorder with macroglossia being one of the cardinal symptoms. In pronounced cases, macroglossia can lead to airway obstruction, musculoskeletal alterations, and functional deficits. Operative tongue reduction exerts a positive influence on skeletal, dentoalveolar and functional development with sufficient long-term outcome and high grade of satisfaction of the patients. A study of national trends showed that partial glossectomy for macroglossia is typically performed prior to age two in the United States. In this case, the patient was diagnosed with Beckwith-Wiedemann syndrome, macroglossia, obstructive sleep apnea, and tracheostomy dependence. Treatment of rare disorders is best performed by specialists with experience in treating these conditions. The medical evidence supports the requested services in this clinical setting. Therefore, an anterior wedge reduction with a W-shaped cut without a tonsillectomy and adenoidectomy is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in otolaryngology 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 Harvoni for treatment of her hepatitis C virus.  Two physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendations for testing, managing, and treating hepatitis C, all patients with chronic hepatitis C should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with HCV genotype 1 regardless of fibrosis stage. In addition, treatment of patients before they progress to F3 or F4 fibrosis is advantageous. In sum, the request for Harvoni has been established as medically necessary in this clinical setting.  Final Result: Two reviewers 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: One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  Two reviewers are board certified in gastroenterology 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

The patient is a 39-year-old female two years post bariatric surgery with a stated 130-pound weight loss. The patient wishes to undergo surgical removal of excess skin and soft tissue from her arms and her abdomen. She is scheduled for a hysterectomy and sought plastic surgical consultation prior to her proposed surgery to see if the procedures could be combined. The patient reports that she has controlled her intertrigo beneath her abdominal pannus with over the counter medications and therefore, has not sought help from her primary care provider for this problem. The Health Plan has denied authorization and coverage for the requested procedures on the basis they are not medically necessary.Based upon the available medical data, the procedures of abdominoplasty and brachioplasty are not medically necessary. The patient has been examined by a plastic surgeon without findings of medical necessity for abdominoplasty or brachioplasty. Thus, there is no indication that the requested procedures are medically warranted in order to treat clinical symptoms or functional complaints. Therefore, I have determined that the requested procedures are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old male enrollee requested authorization and coverage of a mandibular repositioning device. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees obstructive sleep apnea.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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the coronary computed tomography (CT) and the related services performed for the evaluation of the enrollees coronary risk. Findings:  Two physician reviewers found that this patient is diagnosed with type 2 diabetes and hyperlipidemia. The patients provider recommended a coronary calcium score with computed tomography (CT) scan to assist in the management of cardiovascular risk for this patient. The patient requested reimbursement for the coronary CT and the related services performed. The Health Plan denied the reimbursement as investigational for the evaluation of the patients coronary risk. While there are some studies related to the effectiveness of using a coronary calcium score as an assessment tool in this clinical setting, its superior efficacy over current standard modalities has not been established. The American College of Cardiology (ACC) does not give this test a Class I recommendation (should be performed). Instead, the ACC gives it a Class II recommendation (may be done or reasonable). As such, the ACC recommendation for this test, used in this clinical setting, does not carry the strength of a Class I recommendation. Therefore, in this patients case, the computed tomography (CT) and the related services performed were not likely to be more efficacious than the available standard tests for the evaluation of this patient.Final Result: The reviewer determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheldCredentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

A 66-year-old female enrollee has requested a cold therapy unit for the treatment of her torn rotator cuff. Findings:  The physician reviewer found that the medical literature does not demonstrate significant differences in temperature of joints, overall pain control, or in the overall temperatures provided by the use of a cryotherapy cuff versus simple ice and elastic wrap. There is also no difference demonstrated in the literature in regards to functional abilities of patients after the use of those different cold therapy treatments. Active cooling devices are not shown to provide significant differences in temperature provided versus ice packs. A cold therapy unit is thus best viewed as a convenience item and not a medical necessity in this case. The medical record does not document a trial and failure or contraindication to standard ice packs.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a nine-year-old male enrollee has requested speech therapy services for treatment of autism.  Findings:  The physician reviewer found that current medical literature fails to establish the efficacy of speech therapy in the treatment of autism. Because the loss of speech and other behavioral issues are related to communication and social issues associated with autism, there is no medical indication for speech therapy for patients such as this patient. Speech therapy can typically be appropriately provided through means other than private therapy.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 55-year-old female with a long-term history of weakness and fatigue who is requesting authorization for growth hormone for treatment of possible adult growth hormone deficiency (AGHD). Based upon the records provided, the patients presumed diagnosis of AGHD is based on nonspecific symptoms, low IGF-1 concentrations, and a suboptimal response to an arginine growth hormone (GH) stimulation test. The Health Plan has denied authorization for the requested therapy.The diagnosis of AGHD is based upon the clinical context, signs and symptoms, as well as the results of biochemical testing. This patients signs and symptoms are sufficiently nonspecific and GH stimulations tests are sufficiently inaccurate that it is possible the patient has a false positive diagnosis.There is no evidence this patient has AGHD. There are no imaging studies suggesting a structural lesion in the pituitary. Her low IGF-1 levels may be depressed for many reasons including her current medications. The rest of the patients tested pituitary hormones appear normal. Furthermore, the patient had a borderline response to the arginine GH stimulation test. Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.