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

Nature of Statutory Criteria/Case Summary: An enrollee has requested for varicose vein treatment for her bilateral venous insufficiency.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Prior to further intervention for this patient, it is important to reassess the patients current status in order to determine if she requires further vein treatment.  If she is still having debilitating symptoms following her right GSV ablation, sclerotherapy may be appropriate.  Without an assessment of the patients current status and condition, the medical necessity of the requested services cannot be established. Therefore, the requested varicose vein treatment is 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 physician reviewer is board certified in general surgery and vascular 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

The patient has requested authorization and coverage for Lyrica.  The submitted documentation supports the medical necessity of the requested medication. Researchers evaluated various uses of Lyrica for peripheral neuropathy and found that Lyrica should be used as a first line agent in cases where a patient fails to respond to gabapentin. Researchers also reported that there are data demonstrating the efficacy of pregabalin in some patients with painful diabetic peripheral neuropathy (pDPN) who have not responded to other pharmacological treatments, including those unresponsive to treatment with gabapentin. Clinical guidelines acknowledge the paucity of head-to-head data among treatment options, but consistently recommend pregabalin as a first-tier treatment for pDPN. In this case, the medical records indicate the patient tried several doses of gabapentin as instructed by his provider, with marginal benefit. Given the patient has tried and failed gabapentin, and based on the current medical literature, the requested medication is medically indicated. Therefore, Lyrica is medically necessary for the treatment of this patient.Final Result: The reviewer determined 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. 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

The parent of a two-year-old female has requested speech therapy for treatment of her speech delay.  Findings:  The physician reviewer found that the submitted medical records demonstrate the medical necessity of the requested speech therapy in this patients case.  As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability.  The authors reported that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  Per Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  This patient has a history of prematurity.  She demonstrates severe receptive and expressive language delay as well as behavioral problems, which negatively impact her ability to communicate in a functional and age-appropriate manner.  Studies have shown that speech and language therapy can result in significant improvement in this clinical setting.  The current medical evidence supports speech therapy in this case.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a nine-year-old female enrollee has requested speech therapy services for the treatment of the enrollees speech disorder. Findings:  The physician reviewer found that speech and language deficits that persist into the primary school years have long-term effects on literacy, school success, socialization and behavior. Children with cleft lip and/or cleft palate comprise a special subset of such children. Their speech and language difficulties persist despite surgical correction of the physical/anatomical deficits. This is compounded by recurrent otitis media, as well as other congenital difficulties. Ongoing speech and language therapy as part of a multidisciplinary approach is warranted to help these children maximize their ability to communicate effectively. This patient has multiple speech and language challenges, and her skills fall significantly below those of other children her age. These deficits negatively impact her ability to communicate effectively and have resulted in behavioral problems in the past. Consistent speech and language therapy is instrumental in effecting improvement in the communication skills of children such as this patient. She has shown documented improvement in all areas of deficit as a result of her therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested continued PET scans and lab work for an evaluation of her lung cancer. Findings:  The physician reviewer found that the treatments provided are unproven methods of cancer therapy. This includes anti-neoplaston and other therapies. The efficacy of the therapies provided has not been substantiated to the satisfaction of the oncologic community. The requested diagnostic services, including PET scans and lab work, are not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni 90-400 mg tablets for treatment of the enrollees chronic hepatitis C virus genotype 1a.  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 non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks. 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 chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). Although Viekira Pak is also recommended, it is contraindicated in this case due to major drug interaction with estradiol, which is noted to be taken by the patient. The AASLD and IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni for 12 weeks 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: Overturned

The patient is a 55-year-old male with severe asthma.  He has been hospitalized several times and requires frequent treatment with systemic steroids. His IgE was measured at 654 IU/mL in December 2005.  His weight is stated as 86 kg.  The providers request for authorization of Xolair was denied based upon the Health Plans determination that it was not medically necessary to treat the patients asthma.The current recommendation in the literature available on Xolair is that a patient should not be treated only if his IgE is over 700 IU/ml.  Furthermore, this recommendation is not an absolute contraindication. That is, based on the clinical situation, an asthmatic whose IgE is over 700 IU/mL could be treated with Xolair if appropriate precautions were taken and the severity of the asthma, as measured by the systemic steroid requirement, justified that course.  In summary, the patient fulfills the current criteria for Xolair administration. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 63-year-old male enrollee has requested authorization and coverage for Repatha 140 mg/mL syringe. Repatha is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or documented atherosclerotic heart disease who require additional lowering of LDL cholesterol despite of maximally tolerated standard therapy. This patient does not meet these criteria. Based on the records provided for review, the patient presents with a documented coronary disease and dyslipidemia. However, there is no documentation of heterozygous familial hypercholesterolemia. In addition, there is a lack of documentation that the patient has tried and failed Zetia, a medication that has been shown to be safe and effective at lowering cholesterol and is associated with improved cardiovascular outcome. Moreover, the records document a minimal increase in CK without a documented baseline value and without documented myalgia symptoms while on rosuvastatin. Mild asymptomatic CK elevation alone is not considered an indication to discontinue statin therapy. Given these findings, the Repatha 140 mg/mL syringe is not medically necessary for treatment of this patients medical condition. 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: Overturned

This patient is a 72-year-old male who requires symptom control for osteoarthritis and spinal stenosis. He had aortic valve replacement 12 years ago, and as a result will require life-long anticoagulation with Coumadin. The patient was hospitalized nine years ago for a severe hemarthrosis of the left knee accompanied by a severe hematoma of the left thigh. His physician notes that a trial of acetaminophen failed to control his arthritis-related symptoms, and for the past five years that patient has used Celebrex successfully without further bleeding episodes or difficulty managing his anticoagulation. The Health Plan has denied the patients request for continued authorization of Celebrex citing a lack of medical necessity.I find that the use of Celebrex is medically appropriate for this patient.  He has documented osteoarthritis and spinal stenosis and requires an anti-inflammatory medication for control of his symptoms. Additionally, the patient will require life-long anticoagulation therapy because of an aortic valve replacement and previously experienced severe bleeding complications with no obvious abnormalities in his coagulation studies. Acetaminophen did not control his arthritic symptoms and the patient should not use medications with platelet-inhibiting effects due to the increased his risk of bleeding spontaneously or with trauma. Celebrex is the only available anti-inflammatory agent that the patient can use safely in combination with Coumadin therapy. He has been using Celebrex for the past five years with apparent benefit and without bleeding-related problems; treatment with Celebrex should be continued.Based upon the information set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested gene testing for evaluation of the enrollees medical condition.  Findings:  Two physician reviewers found that the requested genetic testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The description of the patient by the geneticist could potentially fit hypermobile Ehlers Danlos syndrome, cardiac type. However, the patient is not described as having an echocardiogram, nor did she have a murmur on exam. There are no skin, skeletal or bleeding issues to suggest other known types of Ehlers Danlos syndrome such as classic or vascular types. There is not enough evidence provided to support the requested gene panel in this clinical setting. Therefore, the requested testing has not been established as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the requested testing is 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 upheld.  Credentials/Qualifications: One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. Two reviewers are board certified in pediatrics and genetics 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: Overturned

A 40-year-old female enrollee has requested for inpatient mental health services for treatment of her major depressive disorder, recurrent, severe, without psychotic features. Findings:  The physician reviewer found that given the patients severe major depression with a suicide attempt with lethal intent, significant psychosocial stressors, the need to assess social support systems and her feelings of being overwhelmed, anxious and pessimistic, inpatient mental health services were medically indicated. The level of care provided was consistent with American Psychiatric Association guidelines for the treatment of major depressive disorder and American Psychiatric Association guidelines for the assessment and treatment of suicidal patients.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: EE requested authorization and coverage bilateral removal of gynecomastia. Findings:  The physician reviewer found that the request for bilateral removal of gynecomastia is medically necessary for treatment of the patients medical condition. The patient presents with bilateral symptomatic gynecomastia without resolution despite attempted weight loss. Work-up of the bilateral masses and possible correctable causes had been evaluated. The photographs submitted for review demonstrate Grade III/IV gynecomastia. In addition, the photographs are supportive of a significant abnormality. Therefore, based on the documentation submitted for review, the request for bilateral gynecomastia surgery is medically necessary.  Final Result: The reviewer determined that the requested surgery is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in plastic 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for peripheral bone density testing for evaluation of the enrollee, who has a family history of osteoporosis. Findings:  Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  The U.S. Preventive Services Task Force recommends testing of all women age 65 and older and younger women whose fracture risk is equal to or greater than that of a 65-year-old woman who has no additional risk factors.  In this case, the patient is premenopausal. Unless she had a secondary condition to suspect osteoporosis, such as glucocorticoid therapy, rheumatoid arthritis, or primary hyperparathyroidism, there is no indication for a baseline bone density test.  Thus, peripheral bone density testing performed was not likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers 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 upheld. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a 4-year-old female enrollee requested authorization and coverage of continued speech therapy for the treatment of speech impairment.  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 therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: At issue is whether the negative pressure wound therapy provided was likely to have been more beneficial for the treatment of the patients condition than any available standard therapy. A review of the records indicates that the patient had an open abdominal wound following a total hysterectomy and bilateral oophorectomy.Two out of three physician reviewers found that there is a lack of support in the literature for negative pressure wound therapy in this clinical setting. The overall wound was not large and the patient was not noted to have high risk factors such as diabetes, obesity, or smoking that are commonly attributed to the failure of traditional treatments. The patient had not failed standard wound treatment. As such, the negative pressure wound therapy was not likely to have been more beneficial than any other available standard treatments. One out of three physician reviewers found that the medical literature supports negative pressure wound therapy (NPWT) systems for the treatment of open wounds as superior to standard wound therapy with respect to speed of closure and in requiring less frequent dressing changes. Therefore, the negative pressure wound therapy provided was likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Final Result: Two out of three reviewers determined that the wound therapy at issue was 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 upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in plastic 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for subcutaneous immunoglobulin therapy. As noted in the medical literature, patients with postural tachycardia syndrome (POTS) can have numerous complaints including syncope, paresthesias, lightheadedness, fatigue and headache. Therapies include increased water or salt intake, support hose, fludrocortisone, clonidine, propranolol, midodrine, and pyridostigmine. There is limited data to suggest immunoglobulin is effective or more effective than any other therapy for POTS. Additionally, repeat autonomic testing evidence is limited to support improved outcomes. This patient has undergone a comprehensive work-up and no underlying autoimmune diseases have been identified to support an indication for treatment with immunoglobulin. Accordingly, the requested subcutaneous immunoglobulin therapy is not medically necessary for treatment of this patients medical condition. 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 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.