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

The parent of a three-year-old female enrollee has requested  speech therapy and occupational therapy for treatment of the enrollees delays in expressive language and fine motor skills.  Findings:  The physician reviewer found that speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success (Nelson and colleagues). Identification of children at risk for developmental delay or related problems may lead to intervention services at a young age when chances for improvement are best.  Speech and language delay must be taken very seriously in young children, as the long-term consequences may be substantial. This patient has severe expressive language delay and articulation deficits. Her skills fall well below those of other children her age. These deficits negatively impact her ability to communicate effectively with peers and adult caregivers. Thus, speech therapy is medically necessary for this patient. This patient has significant deficits in fine and gross motor skills, self-regulation, bilateral coordination, oral motor skills, feeding skills, and self-help skills, negatively impacting her ability to carry out the usual occupations of childhood, such as play and social interaction. With its focus on developing motor planning skills and self-help skills, developing age-appropriate communication skills (written and functional), processing information, and regulating the response to incoming information, occupational therapy is ideally suited to affect positive change in this patient. Therefore, occupational therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 37-year-old female enrollee has requested an ear nose and throat (ENT) consultation with a tertiary level provider who specializes in head and neck oncology for treatment of her left submandibular solid mass.  Findings:  The physician reviewer found that based on review of the available records, the patient has a parapharyngeal space tumor. Parapharyngeal space tumors are rare and require the services of head and neck oncologists. Nearly all reports of this type of tumor are treated by head and neck oncologists at tertiary care medical centers (Chang, et al; Khafif, et al). These tumors are rarely removed by general otolaryngologists. For these reasons, it is appropriate that the patient undergo consultation with a tertiary care head and neck oncologist as requested. Therefore, the requested services are supported as medically necessary for treatment of this patients 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 continued orthoptic training for treatment of her binocular vision disorder.  Findings:  The physician reviewer found that there is a lack of support in the medical literature for the requested services in this clinical setting. The goal of orthoptic therapy is to stimulate and normalize accommodative, oculomotor and vergence abilities. The endpoint of orthoptic therapy for these conditions is when the patient is able to maintain clear, single binocular vision with a series of orthoptic tasks. Eye conditions such as convergence insufficiency, accommodative insufficiency, and ocular motor dysfunction are successfully treated with orthoptic therapy. Each of these eye conditions often presents with symptoms of blurred vision at near, discomfort, strain and headaches and fatigue associated with near tasks.  The literature provides a solid base of research supporting vision therapy as an effective treatment mode for oculomotor, accommodative and convergence deficiencies. However, the standard treatment time for these conditions is between 12 to 24 sessions.  For this patient, 30 sessions were completed over a 12 month time period. As such, in this patients case, her sessions have exceeded the typical treatment times. The medical literature does not support additional orthoptic therapy sessions in this clinical setting. The likelihood that additional orthoptic therapy sessions will improve this patients condition is low. Accordingly, continued orthoptic training is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in optometry with expertise in pediatric optometry 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 is requesting Harvoni for the treatment of his hepatitis C infection. 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.  The guidelines recommend that treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks.  These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  For these reasons, the requested Harvoni 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 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

A 43-year-old female enrollee requested authorization and coverage of synvisc injections for the treatment of osteoarthritis.  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 overturned the health plans denial on the basis that the requested injections are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for Taltz. Taltz is a monoclonal antibody that inhibits interleukin 17a. The U.S. Food and Drug Administration has approved Taltz for patients with moderate to severe plaque psoriasis. A recent joint statement of the American College of Rheumatology and the National Psoriasis Foundation provided a Class A recommendation for the use of Taltz as monotherapy for patients with plaque psoriasis with associated psoriatic arthritis. In this patients case, the records document plaque psoriasis with associated arthritis. He has failed topical and oral small molecular (OSM) treatment. In this case, an interleukin 17a inhibitor is the appropriate next line of therapy. This patient has plaque psoriasis over his knees and elbows. Arthritic symptoms are noted in multiple joints. The medical evidence supports the requested medication in this clinical setting. Therefore, Taltz is medically necessary 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 dermatology 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

A 51-year-old male enrollee has requested for a follow-up consultation with a neurologist for treatment of his, who is status post stroke. Findings:  The physician reviewer found that this patient is status post stroke with apparent good recovery.  He remains on Coumadin despite the fact that he is greater than six months out from his probable embolic infarct. He was referred for follow-up evaluation by a neurologist to address post-stroke care, education and future issues. Standard of care includes neurology involvement for patients with cerebrovascular accidents, both acutely and in follow-up.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old male enrollee has requested authorization and coverage for Betaseron for treatment of the enrollees multiple sclerosis. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication in this patients case.  This patient has been started on disease modifying therapy with Betaseron (interferon-beta-1b).  Patti and colleagues conducted a six-year head-to-head study and concluded that both interferon-beta-1a and interferon-beta-1b are effective in slowing disability progression.  Pan and colleagues conducted an analysis of long-term results with Betaseron and reported that treatment with Betaseron during the earlier disease phase of patients with multiple sclerosis significantly increased quality-adjusted life-years.  This patient has been diagnosed with multiple sclerosis, and Betaseron has been shown to reduce long-term disability.  The current medical evidence supports the requested medication in this clinical setting.  All told, Betaseron is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 27-year-old female enrollee has requested for proton beam therapy for treatment of her metastatic colorectal cancer. Findings:  Three physician reviewers found that proton beam therapy has been utilized for certain malignant and nonmalignant conditions including melanoma of uveal tract, skull base chordoma and chondrosarcoma, pituitary adenoma, intracranial arteriovenous malformations, primary and metastatic central nervous system (CNS) malignancies and clinically localized prostate cancers. However, there is no data suggesting that the use of proton beam therapy for metastatic colon cancer is superior to alternative treatment techniques such as intensity modulated radiation therapy (IMRT) or 3-D conformal therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 22-year-old female enrollee has requested residential treatment for her bulimia nervosa, generalized anxiety disorder, major depressive disorder, recurrent, eating disorder, not otherwise specified and attention deficit/hyperactivity disorder.   Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  This patients psychiatric symptomatologies were refractory to outpatient treatment efforts and had necessitated a higher level of care previously.  Psychopharmacotherapy had minimal effects on her symptoms.  Upon presentation to the facility, appropriate individualized and patient-centric treatment goals were developed.  It was expected that the disputed services would improve her condition and prevent a more serious condition.  During her residential stay, the patient received therapies delivered in accordance with a unique treatment plan.  The medical records indicated that she was actively engaged in treatment.  Considering the clinical presentation and longitudinal patient history, coupled with relevant peer-reviewed medical literature and current practice guidelines, residential treatment services were medically necessary.  All told, residential treatment provided during the said timeframe was medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 36-year-old female with pelvic pain who has had two pregnancies, tubal ligation, total vaginal hysterectomy (2003) and a laparoscopic diagnosis of endometriosis (1993). The records also indicate a diagnosis of depression. The patient presents with a four-month history of severe pelvic pain. She desires pelvic laparoscopy, but her in-Plan provider would like her to have a more definitive evaluation including a consultation with a pelvic pain specialist that is within the Health Plan. The patient self-referred to a non-Plan gynecologist who suggests she will benefit from laparoscopy with possible resection of deep endometriosis. The patients request for authorization of laparoscopy of the pelvis performed by a non-Plan provider was denied by the Health Plan based upon a determination that the requested services are not medically necessary.Diagnostic evaluation and management of chronic pelvic pain (CPP) presents a challenge for the treating gynecologist. CPP may be caused by or related to both gynecologic and non-gynecologic disorders. This ambiguity of symptoms and etiology complicates treatment and an interdisciplinary approach is often needed for optimal management. Although this patient may ultimately require a laparoscopy, she has not yet been adequately evaluated and in-Plan resources have not been fully utilized. The Health Plans recommendation for an in-Plan referral to a chronic pelvic pain specialist is a medically appropriate course of treatment prior to surgical intervention.  Based upon the information set forth above, I have determined the requested services are not medically necessary for evaluation of the patients medical condition at this time. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for the Eylea injections for treatment of the enrollees left eye non-ischemic central retinal vein occlusion.   Findings:  The physician reviewers found that based on current peer-reviewed medical literature, Eylea was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, there is an absence of macular edema. Clinical trials using Eylea demonstrate that the medication is effective at treating central retinal vein occlusion (CRVO) complicated by macular edema. This patients records demonstrate that the patient has not experienced macular edema as evidenced by the examination notes and optical coherence tomography (OCT) images of the macula. Final Result: All three reviewers determined that the medication at issue was not and is 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: Physician reviewers number one, two, and three are board certified in ophthalmology and 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

The patient is a 47-year-old female who is 411 and weighs 123 pounds. She has large pendulous breasts. The submitted chart notes indicate the patient has been experiencing cervical/thoracic pain secondary to large breasts for four years. The patients physician has recommended the patient undergo bilateral breast reduction surgery. The Health Plan has denied this request indicating the requested procedure is not medically necessary.The patient meets medical necessity criteria for authorization of breast reduction surgery.  The consulting breast surgeon anticipates removal of at least 300 grams of breast tissue. In addition, the patient has lower cervical and thoracic back pain that has been present for more than one year, and etiology other than breast weight has been reasonably ruled out.Furthermore, the patients pain has been of such severity that she has sought medical treatment. For these reasons, bilateral breast reduction is medically appropriate and indicated for this patient. Accordingly, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested 32 hours per week of direct intensive applied behavioral analysis (ABA) therapy for treatment of the enrollees medical condition. Findings:  Two physician reviewers found that the request for 32 hours per week of direct intensive of ABA therapy of which 24 hours to be rendered in the school setting are medically necessary for treatment of the patients medical condition. The study by Orinstein and colleagues found that children with optimal outcome from autism spectrum disorders (ASD) had started therapy earlier and had more ABA services. ABA therapy is medically necessary for the treatment of autism spectrum disorders. In addition, ABA services should be performed in the appropriate setting for the particular patient. In this case, there has been a regression of the patients autism-based behaviors in the classroom setting that are interfering with his academics. Given the above, the requested ABA hours in the classroom setting are medically necessary for treatment of the patients medical condition.  Final Result: Two 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: One reviewer is board certified in child neurology and is actively practicing. One reviewer is board certified in pediatrics and child neurology and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested pelvic floor physical therapy for treatment of her medical condition.  Findings:  The physician reviewer found that chronic pelvic pain syndromes are not uncommon and can cause impaired quality of life.  These pain syndromes, including pudendal neuralgia, are poorly understood, and there is limited high-grade evidence available to guide treatment.  In this patients case, there are no objective indications that the formal physical therapy services that she has been receiving have been effective or necessary.  Despite the therapy interventions that were being provided, she had persistent symptoms that fluctuated and generally worsened.  She continued to have pain and functional limitations.  She required ongoing injection therapy and increases in her pain medications.  There were no exercises or modalities performed in the formal therapy setting that could not have been performed independently or substituted with independent exercises or modalities with a reasonable expectation of differences in clinical course or outcomes.  The patient should have already been transitioned to an independent program.  Formal manual therapy on a chronic basis in the setting of chronic neuromusculoskeletal pain conditions is not proven to be effective in the medical literature.  All told, the requested pelvic floor therapy is not medically indicated 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 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 a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for occipital nerve block therapy. As noted in the peer-reviewed medical literature, occipital nerve blocks have not been demonstrated to be safe and effective for the treatment of migraine or other types of headache. Researchers found that there was no evidence of long-term improvement of chronic migraine type headache with occipital nerve blocks. Similarly, other researchers also reported that greater occipital nerve blocks do not reduce the frequency of moderate to severe migraine days in patients with episodic or chronic migraine compared to placebo. Given these findings, the occipital nerve block therapy was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the occipital nerve block therapy was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the occipital nerve block therapy was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewer 1 is board certified in neurology with subspecialty certification in pain management and is actively practicing. Physician reviewer 2 is board certified in neurology with subspecialty certification in sleep medicine and is actively practicing. Physician reviewer 3 is board certified in neurology and is 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.