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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Krystexxa (pegloticase) 8 mg intravenous (IV) every two weeks x 12 months. The American College of Rheumatology (ACR) guidelines recommend treatment with Krystexxa over continuation of uric acid lowering therapy for patients with two or more gout flares per year who are not candidates for treatment with xanthine oxidase inhibitors such as allopurinol or uricosurics, and other interventions have failed to achieve target uric acid levels (FitzGerald, et al.). However, the ACR guideline indicates that an optimal trial of oral therapy with allopurinol should be performed prior to treatment with Krystexxa use due to the potential adverse effects of Krystexxa. The ACR states that allopurinol is the preferred first-line agent to treat gout given its efficacy when dosed appropriately. As noted in the U.S. Food and Drug Administration (FDA) approval, treatment with allopurinol often requires doses more than 300 mg per day up to the maximum FDA-approved dose of 800 mg per day. This patients records document a diagnosis of gout. The provider noted that the patient has been treated with up to 300 mg daily of allopurinol, but not up to 800 mg per day. Per the ACR guidelines, the patients allopurinol dosing should be optimized prior to switching to Krystexxa. Moreover, there is a lack of report that the patient has been treated with, or has a contraindication to, other agents such as probenecid prior to consideration for treatment with Krystexxa. For these reasons, the requested authorization and coverage for Krystexxa (pegloticase) 8 mg IV every two weeks x 12 months is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in rheumatology 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 12 weeks for treatment of her hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, 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.  All told, Harvoni for 12 weeks is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation therapy.Findings:  The physician reviewer found that is a lack of medical evidence to support that treatment with proton therapy is associated with a clinical benefit compared to treatment with photons. In addition, proton therapy has not been validated in comparative randomized studies as compared to conventional treatment with photons. With regard to prostate cancer, there is insufficient clinical data to discern that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques. A recent multi-institutional analysis of 1,850 patients with low or intermediate risk prostate cancer compared groups receiving hypofractionated radiation proton therapy and intensity modulated radiation therapy (IMRT) with photons. This analysis found no significant difference in gastrointestinal or genitourinary toxicities between the two treatments. Furthermore, the study reported no difference in disease control between the two modalities. Per the American Society of Radiation Oncology (ASTRO), Proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry. The National Comprehensive Cancer Network (NCCN) guidelines endorse the position statement by ASTRO and state that there is inadequate data showing benefits with proton therapy over photons and IMRT technique. Given these findings, the requested proton beam radiation 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 radiation oncology 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 patient has requested reimbursement for Orthovisc injections provided by Kavoos Nazeri, M.D. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the services at issue were medically indicated. Therefore, Orthovisc injections provided by Kavoos Nazeri, M.D., were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 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-ten-month-old male has requested occupational therapy for treatment of his autism. Findings:  The physician reviewer found that review of the available peer reviewed medical literature indicates that occupational therapy is a medically necessary intervention for the treatment of patients diagnosed with autism. Additionally, a defined trauma, surgical intervention, or musculoskeletal condition is not necessary for abnormal gross and fine motor development that is seen in children with autism. Occupational therapy administered during critical developmental periods in childhood is a medically appropriate intervention and is clinically indicated for this patient based on his documented deficits.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old female requested authorization and coverage of gastric bypass surgery with duodenal switch. The Health Plan  denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested surgery is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old female enrollee requested authorization and coverage of humatrope growth hormone for the treatment of panhypopituitarism.  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 services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xtampza, Percocet, and Soma. The Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioid medications assist providers in making decisions regarding initiating, adjusting and discontinuing of opioid therapy. The guidelines do not provide a hard limit to the prescribing of opioid medications for chronic pain patients. To clarify these issues, the CDC recently announced that providers should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. The Federation of State Medical Boards (FSMB) guidelines state continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. The FSMB noted that opioid dosage should be maintained as low as possible and continue[d] only if clear and objective outcomes are being met. In this case, the patient has multiple pain generators in the lumbar spine, cervical spine, and knee. The patient has documentation of pathology in these areas. Her pain management regimen has included chronic opioid therapy. Treatment with non-opioid therapies have failed to produce adequate pain control. Previous attempts to taper her medications have led to a clinically significant decrease in functionality and inhibition of the performance of her activities of daily living. The records document the patient has shown a clinically meaningful improvement in pain and function that outweighs risks to patient safety to support continued opioid treatment. Further, the records state the patient has been compliant with her regimen of Xtampza and Percocet. Thus, Xtampza and Percocet are medically necessary for treatment of this patient. However, there is a paucity of evidence supporting the safety and effectiveness of Soma. Researchers found that studies demonstrate the efficacy of skeletal muscle relaxers for up to 14 days after symptom onset, and the evidence for long-term use is lacking. Given the lack of peer-reviewed medical literature demonstrating benefits for chronic low back or neck pain, Soma is not indicated. Therefore, Soma is not medically necessary for the treatment of this patients chronic low back and neck pain.Final Result: The reviewer determined that a portion of the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

A thirty-two year-old male with degenerative disc disease of the lumbar spine with radiculopathy is requeting authorization for percutaneous disc decompression.  Reviewers Findings:  The reviewing physician found that at this time percutaneous disc decompression is an unproven procedure without established clinical efficacy.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for occipital nerve blocks for treatment of the enrollees headaches. Findings:  Two of the three physician reviewers found that there is sufficient support for the requested services in this clinical setting. This patients history is consistent with transformed migraine into chronic daily headache from pre-existing episodic migraine headache. This is often responsive to prophylactic medications. However, the patient has failed an exhaustive trial of these agents.  Bilateral greater occipital nerve blocks under the circumstance represents a reasonable and documented efficacious procedure. Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 37-year-old female with a body mass index (BMI) of 46 and obesity related comorbidities. She has requested authorization for bariatric surgery. She has obtained psychiatric clearance for weight loss surgery. The Health Plan has denied authorization for gastric bypass on the basis it is not medically necessary for treatment of the patients morbid obesity.With a BMI of 46 and comorbid conditions such as diabetes mellitus and hypertension, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no clinical evidence demonstrating that further weight loss is necessary for a successful surgery and there is no scientific evidence supporting this requirement. Therefore, I have determined 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: Upheld

The patient is a 70-year-old male with a complex medical history including bronchoalveolar carcinoma, coronary artery disease, cerebral vascular accident, chronic obstructive pulmonary disease, two myocardial infarctions and angioplasty in 2002. He is receiving chemotherapy and was recently hospitalized for a gastrointestinal bleed.  The patients physician has recommended a POV. The Health Plan has denied this request on the basis that a POV is not medically necessary for the patients mobility.The occupational therapy evaluation of December 2005 indicates the patient is independent with transfers, activities of daily living, and gait for short distances. Strength was within normal limits. The occupational therapist did not recommend a POV as the patient is independent at home with use of a walker. Review of the physicians notes does not reveal any documentation of facial weakness or sensation or balance issues. Furthermore, the physicians notes do not indicate the patient is unable to walk for household distances. Therefore, I have determined the requested POV is not medically necessary for the patients mobility. Accordingly, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a total electric hospital bed, E0265. Gillespie and colleagues report that there is currently no strong evidence of a reduction in pressure ulcers with a 30-degree tilt compared with the standard 90-degree position. Jocelyn Chew and colleagues found that results regarding turning and repositioning schedules for adult bed-bound patients were inconclusive. In this case, the patient had mobility impairments after being newly diagnosed with ovarian/peritoneal neoplastic disease and undergoing treatment, included chemotherapy. At home, she was at risk for pressure injury due to her impaired mobility, aspiration and worsening leg edema. These positioning needs can adequately be met with a semi-electric hospital bed with an appropriate mattress surface. A total electric hospital bed adds an electric height adjustment feature that may be necessary for patients requiring a height adjustment for independent transfers into and out of bed, however, the documentation in this case does not show that this feature is medically indicated for this patient. Therefore, a total electric hospital bed, E0265 is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 59-year-old male requesting coverage for treatment with growth hormone (GH) therapy for adult growth hormone deficiency (AGHD). He is being treated for hypothyroidism secondary to radioiodine ablation of an overactive thyroid, dyslipidemia, and depression.  The patient has also been given the diagnosis of metabolic syndrome presumably on the basis of his obesity and dyslipidemia for which he was started on metformin. He had a normal level of IGF-1 and normal GH stimulation testing according to his endocrinologist. He is noted to have adrenal insufficiency but is on no pituitary tropic hormone replacement and no pituitary function tests are submitted to substantiate the clinical diagnosis.  His testosterone, cortisol, DHEA, TSH and alpha subunit hormone tests are all normal.  The Health Plan has denied authorization and coverage for GH therapy based upon their determination that it is not medically necessary.The medical records from the patients treating endocrinologist from December 2003 through August 2005 do not substantiate the diagnosis of AGHD.  The patient has normal GH function testing and there is no evidence of any other pituitary dysfunction to support a diagnosis of panhypopituitarism. Patients who have documented AGHD do have an increased incidence of coronary artery disease and increased mortality. However, the use of GH in patients with metabolic syndrome to prevent an acute coronary event is experimental at this time.Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old female enrollee has requested coverage for continued acute in-patient adolescent level of care with discharge/step-down to a psychiatric residential treatment program for treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found that the American Academy for Child and Adolescent Psychiatry (AACAP) Practice Parameter for depression, states the clinician, together with the child and parents, should evaluate the appropriate intensity and restrictiveness of care. The decision for the level of care will depend primarily on level of function and safety to self and others, which in turn are determined by the severity of depression, presence of suicidal and/or homicidal symptoms, psychosis, substance dependence, agitation, childs and parents adherence to treatment, parental psychopathology, and family environment. Ultimately the interpretation and application of clinical guidelines and patient placement criteria falls upon physicians and therapists working directly with the patient population.