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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with hypertension. An echocardiogram revealed moderately reduced systolic function and an ejection fraction of 35%. The patient underwent cardiac catheterization due to chest pain. The report noted non-obstructive coronary artery disease. The patient was noted to have a history of hypertension, hyperlipidemia, and coronary artery disease. There was no report of chronic congestive heart failure (CHF) symptoms or signs of CHF in the physical examination. The patient was being treated with Coreg, Lipitor, and lisinopril. The patient has requested authorization and coverage for Entresto. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Entresto is medically necessary for the treatment of the patients medical condition. Entresto is an angiotensin receptor-neprilysin inhibitor (ARNI). Yancy and colleagues reported, In patients with chronic symptomatic reduced ejection fraction New York Heart Association (NYHA) class II or III who tolerate an angiotensin-converting-enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB), replacement by an ARNI is recommended to further reduce morbidity and mortality. In this case, the patient does have a reduced ejection fraction; however, the only reported symptom noted was chest discomfort, which places him in the NYHA class I (asymptomatic with regard to heart failure symptoms). There was no report of symptoms of CHF in the medical records and no signs of CHF reported in the physical examination. The medical evidence does not support the requested medication in this clinical setting. Therefore, Entresto 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 the 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 cardiovascular disease 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 15-year-old female enrollee has requested  clobazam (Onfi) for treatment of the enrollees epilepsy.  Findings:  The physician reviewer found that Onfi has been approved for use in Lennox-Gastaut syndrome. In addition, Onfi has been demonstrated to be safe and effective in pediatric patients with refractory epilepsy. Further, Onfi has been has been evaluated for use in children with febrile seizures and was found to be superior to diazepam due to similar efficacy but lower adverse effects such as drowsiness and sedation. However, this patients records lack a clinical description of the patients seizures other than noting that the EEG shows a risk to developing generalized seizures. There are other available medications for the treatment of this patients generalized seizures that are less teratogenic than Depakote. All told, the records do not support the request for Onfi as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for eight weeks for treatment of his hepatitis C virus (HCV).  Findings:  The physician reviewer found that the position of American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) on HCV does not stratify patient as early or late. The recommendation is not to deny patients treatment if they have early stage disease, but to provide treatment to avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from HCV. A report of long-term follow-up of 820 patients with biopsy-confirmed stage F0 or F1, a 15% rapid progression of fibrosis was noted, as compared to those who were treated earlier where the long-term survival was better. Moreover, post-hoc analysis has revealed that non-cirrhotic HCV genotype 1 patients who are treatment naive and have a viral load of less than 6,000,000 IU/mL can be treated with an eight week course instead of 12 weeks and achieve similar cure rates. Therefore, Harvoni for eight weeks is medically necessary based on national guidelines. 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cervical total disc 2 level arthroplasty C6-C7 for treatment of the enrollees damaged cervical discs. Findings: Three physician reviewers found that Current evidence based medical peer reviewed literature supports 2 level cervical artificial disc replacement at two contiguous levels for intractable radiculopathy (arm pain and/or neurologic deficit) when specific criteria have been met. There is limited support for hybrid surgery (artificial disc replacement and anterior cervical discectomy and fusion) using the Bryan prosthesis for bi-level degenerative disc disease. However, a review of current medical literature did not reveal evidence based medical support for the addition of an artificial disc at the adjacent level to the Bryan prosthesis. This patient presents status post a C5-6 artificial disc replacement using the Bryan prosthesis. He has developed significant left C6-7 radiculopathy confirmed by imaging evidence of adjacent segment disease, and electrodiagnostic evidence of an acute C6-7 radiculopathy. He had apparently failed reasonable conservative treatment. The treating provider has opined the clinical necessity of adjacent level surgery. However, there is a lack of current peer reviewed support for the addition of a second cervical artificial disc replacement at the adjacent level next to a Bryan artificial disc replacement. There is limited support noted for a hybrid surgery combining the existing Bryan artificial disc with an anterior cervical discectomy and fusion. Therefore, cervical total disc 2 level arthroplasty at C6-7 is not likely to be more beneficial for the treatment of this patients medical condition than any available standard therapy.Final Result: The three physician reviewers determined that the requested procedure 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. All three physician reviewers are board certified in orthopedic surgery and are actively practicing. The reviewer 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: The patients parent has requested authorization and coverage for continued speech therapy. The records provided for review demonstrate that this patient has made gradual progress with speech therapy as noted during his evaluation. The American Speech-Language-Hearing Association (ASLHA) reports that, Childhood apraxia of speech (CAS) is a neurological childhood (pediatric) speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits. With regard to treatment, researchers described that young patients with CAS may also have impairments in one or more of the following areas: non-speech oral motor function, dysarthria, language, phonological production impairment, phonemic awareness or metalinguistic skills and literacy, or combinations of these. This patients provider reports slow progress but noted that the patient continues to exhibit severe impairments across receptive, expressive and speech production skills. Consistent with the current medical literature and ASHA guidelines, continued speech therapy is appropriate as recommended by the patients provider. All told, the requested continued speech therapy is medically necessary for treatment of this patient. Final Result: The reviewer 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: The reviewer is board certified in neurology with special qualification in child 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: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for risdiplam. Mercuri and colleagues describe spinal muscular atrophy (SMA) as an autosomal recessive disorder characterized by degeneration of motor neurons in the spinal cord and caused by mutations of the survival of motor neuron 1 gene (SMN1). Messina and Sframeli note that nusinersen (brand name Spinraza), an antisense oligonucleotide, may be used to treat SMA. Dhillon reports that risdiplam is approved by the U.S. Food and Drug Administration (FDA) for the treatment of SMA. While risdiplam is given orally, nusinersen is administered intrathecally, and both medications are modulators of SMN2 splicing. In this case, the patient has advanced SMA type 1 and has shown no improvement since starting treatment with Spinraza, a SMN2 splicing modulator drug with the same action mechanism as the requested medication. Given the advanced stage of the patients disease and lack of clinical, objective improvement following three years of treatment with Spinraza, the requested medication is not medically indicated. Therefore, risdiplam 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 the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child 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: An enrollee has requested Harvoni for treatment of her hepatitis C virus. Findings:  The physician reviewer found that according to the 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 non-liver-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 eight weeks. These guideline recommendations are based on multiple randomized clinical trials. In addition, the patient is not eligible for the alternative for genotype 1a (Viekira Pak with ribavirin) due to a pre-existing condition, which can be exacerbated by ribavirin.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment . For these reasons, the requested treatment with Harvoni is 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 enrollee is requesting authorization and coverage for free T3, reverse T3, progesterone-ester and testosterone testing, as outlined in the Bredesen Protocol. The enrollee has severe dementia. She has experienced a steady decline over the past 10 years. The tests recommended under the Bredesen Protocol are necessary to determine the drivers of the enrollees Alzheimers. A search of the clinical trials in progress revealed that there is currently an ongoing study, though observational and with no control group, to determine the efficacy of the Bredesen protocol in 30 persons with either Alzheimers dementia or mild cognitive decline. Since this treatment would be considered complementary or alternative medicine, a separate search of a relevant site found nothing under Bredesen protocol. A separate search revealed only anecdotal studies, or, in the most recent Bredesen publication, a report on ten individuals with no controls. Thus, at this time there are no data in the scientific literature that supports the use of this protocol outside of a research study. This protocol has not been rigorously tested and is not considered medically necessary for the treatment of dementia.  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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 32-year-old female enrollee has requested Harvoni for treatment of her hepatitis C genotype 1a.  Findings:  Two physician reviewers found that per the American Association for the Study of Liver Diseases (AASLD) guidelines, patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Consistent with this support, this patient should be approved for Harvoni as recommended by her provider. Therefore, based upon these findings, the requested Harvoni is medically necessary in this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee requested authorization and coverage of optic nerve surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees left eye proptosis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old female enrollee has requested authorization for a needle aponeurotomy for evaluation of bilateral Dupuytrens contracture.  Findings:  Two physician reviewers found that review of the medical evidence reveals insufficient peer-reviewed data demonstrating the efficacy of needle aponeurotomy for treatment of patients such as this patient. Standard treatment for worsening Dupuytrens contracture is not a needle aponeurotomy, but rather, surgical release.  Although there seems to be higher patient satisfaction with needle aponeurotomy, review of the relevant literature demonstrates that results are not superior to those of percutaneous fasciotomy. The data shows needle aponeurotomy carries with it a greater chance of recurrence and incomplete correction.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested partial hospitalization program services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The current medical evidence does not support partial hospitalization program level of care in this clinical setting.  Her motivation is fair and she has no comorbid medical or psychological conditions that require intensive treatment.  Her family is supportive and working with the treatment team to support her upon discharge.  All told, partial hospitalization program services were not and are not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested authorization and coverage for percutaneous laser disc decompression (nucleoplasty).  The health plan has denied this request indicating that nucleoplasty is considered experimental for treatment of the enrollees back pain.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three-physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollee's condition than any available standard therapy.  The health plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested a nutritionist for dietary/nutritional counseling for treatment of her osteoporosis Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested services.  She has requested coverage for a nutrition consult for the treatment of osteoporosis.  According to current guidelines for the treatment for osteoporosis, the dietary recommendation consists of increasing dietary calcium and vitamin D.  Patients are educated regarding lifestyle modifications, including dietary changes and vitamin supplementation, from their primary care provider.  Therefore, the requested referral to a nutritionist for dietary/nutritional counseling is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old male enrollee has requested Zetia 10 mg for the treatment of his coronary disease. Findings:  The physician reviewer found that this patient has multivessel stenting and diabetes and is at very high risk of developing future coronary events and aggressive lipid therapy is warranted. This conclusion is consistent with the findings by Smith and colleagues and the American Heart Association/American College of Cardiology guidelines referenced above. Elevated homocysteine levels have been shown to put patients at higher risk of future atherosclerotic disease. Although further studies are needed, it is common clinical practice to attempt to lower homocysteine levels with medications in very high risk patients such as this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for weekly play therapy. Play therapy is a form of psychodynamic psychotherapy for young patients, which is based from a belief that a childs play has symbolic unconscious meaning. Patients that can benefit from play therapy are interested in school and hobbies, communicates with others at an age appropriate level, is aware of his symptoms, and is ready for change. This patients records do not demonstrate that this patient meets these criteria. The documentation reports that this patient is experiencing problems adjusting to his parents divorce. The American Academy of Child and Adolescent Psychiatry (AACAP) recommend ongoing individual therapy and family therapy to help cope with this major life stressor. Cognitive behavior therapy (CBT) principles like emotion regulation and coping skills are also helpful for many patients in this clinical setting. However, the records provided for review do not support an indication for play therapy. All told, the requested weekly play therapy 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 psychiatry with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female enrollee requested acute inpatient psychiatric services for medical treatment of her depression, anxiety, and self-harm.  Findings:  The physician reviewer found that per the American Psychiatric Association (APA) practice guidelines, the emergency psychiatric evaluation generally occurs in response to thoughts, feelings, or urges to act that are intolerable to the patient, or to behavior that prompts urgent action by others, such as violent or self-injurious behavior, threats of harm to self or others, failure to care for oneself, bizarre or confused behavior, or intense expressions of distress. This patients records documented that she was placed on a 5150 hold after she presented to emergency department with symptoms of generalized weakness, feeling severely anxious and her whole body was tremulous. The patient had severe panic related symptoms for which outpatient treatment with medications prescribed a few days prior to the emergency evaluation were not helpful. The APA also notes that in this clinical setting, inpatient treatment provides a highly structured and contained setting in which patient safety can be monitored and optimized, and permits intensive and continuous observation of signs and symptoms while the patient is being treated. Consistent with these recommendations from the APA, the inpatient treatment provided to this patient was medically necessary for continuous observation of her signs and symptoms during treatment.