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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dupixent Solution Pen-Injector 300 mg/2 mL. Findings:  The physician reviewer found that the medical literature, Hailey-Hailey disease (HHD) is a genetic condition that results in blistering of the skin. Currently, there is a lack of specific approved treatments for the condition, and the literature has mainly case reports of treatments that have worked for certain patients. The records provided for review document that this patient has experienced severe symptoms for many years as have many of her relatives. The patients provider reports that the HHD condition causes the patient severe pain and discomfort. The patient has tried and failed several topical and systemic treatments including Botox, naltrexone, systemic and topical steroids, antibiotics, antifungals, cyclosporine, and tacrolimus. One case series described successful use of Dupixent in three patients with severe HHD with control of the disease for at least 17 months, no flares, and no side effects (Alzahrani, et al.). In addition, the patients daughter has HHD and is being treated with Dupixent with good results, per the providers letter. Given the findings in the medical literature and successful treatment of the patients daughter with Dupixent considering the genetic nature of the condition, treatment with Dupixent is appropriate for this patient. Therefore, requested Dupixent Solution Pen-Injector 300 mg/2 mL is medically necessary for 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: Upheld

The parent of a 12-year-old male enrollee requested Ensure enteral formula and enteral feeding supplies (syringes, Ensure, extensions and tubes for the treatment of the enrollees medical condition.  Findings:  The physician reviewer found that  submitted documentation fails to demonstrate the medical necessity of the requested formula and supplies.  Historically, this patient apparently had issues with feeding orally, because he required gastrostomy tube placement for nutrition.  Currently, no documentation has been submitted to support or refute ongoing need for gastrostomy tube feedings.  Although he is taking some nutrition by mouth, there is no mention of whether this is adequate to sustain him.  In summary, the submitted information is not sufficient to justify medical necessity for ongoing Ensure supplementation.  All told, the requested Ensure enteral formula and enteral feeding supplies (syringes, Ensure, extensions and tubes) are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

An 18-year-old male enrollee has requested inpatient treatment for the treatment of his behavioral health problems. Findings:  The physician reviewer found that the evidence demonstrates the medical necessity for continued treatment of this patient in a 24-hour treatment setting. The patient continued to have difficulties with insight regarding relapse, there was minimization of the severity of his addiction, and there was anxiety and ambivalence on his part. Overall, there was significant potential for relapse with services at a lower level of care; thus, continued treatment in a 24-hour subacute setting was medically necessary and consistent with Child and Adolescent Level of Care Utilization System (CALOCUS) criteria and American Psychiatric Association (APA) practice guidelines.
Appeal type: Medical Necessity
Decision: Overturned

A 28-year-old female enrollee requested authorization and coverage of the medication Lupron or Zoladex. The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollees medical condition.  One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for applied behavioral analysis (ABA) therapy services three hours each day, and five days per week at home. The Council of Autism Service Providers guidelines on ABA treatment of autism spectrum disorder note that treatment intensity will vary with each patient and should reflect the goals of treatment, specific patient needs, and response to treatment. The guidelines further note that discharge from treatment can begin when the patient does not demonstrate progress towards goals for successive authorization periods. Papatola and Lustig report that ABA services should be consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research. In this case, the patient has made minimal progress over an extended period of time and continues to display deficits. Given that further treatment is unlikely to ameliorate symptoms, deceasing service intensity is standard of care and the requested services are not medically indicated in this clinical setting. Therefore, applied behavior analysis therapy services three hours each day, and five days per week at home are 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 reviewer is a licensed B.C.B.A, board certified in psychology, and is actively practicing 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 surgery with a Cartiva implant synthetic of the right first metatarsophalangeal (MTP) joint. While the medical literature does show some early promising results with the use of the Cartiva implant for the treatment of hallux rigidus, there is a lack of high-quality studies demonstrating long-term safety and efficacy. The gold standard for treatment of hallux rigidus remains arthrodesis. This patients records do not include radiology studies that grade the severity of the patients degenerative changes of the great toe MTP joint. Therefore, the requested surgery with a Cartiva implant synthetic of the right first MTP joint is not likely to be more beneficial for the treatment of the patients medical condition and any available standard therapy.Final Result: Two of the three reviewers determined that the requested services are 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:  Reviewers 1, 2, and 3 are board certified in orthopedic surgery 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: Experimental/Investigational
Decision: Overturned

A 61-year-old male has requested approval for transcatheter arterial chemoembolization (TACE) with drug eluting beads for treatment of his multifocal hepatocellular cancer.   Findings:  Three physician reviewers found that the patient has a history of hepatitis C with liver cirrhosis.  He was diagnosed with multifocal hepatocellular carcinoma.  Per the medical records, his disease appears to be confined to the liver.  However, he is not deemed to be a candidate for surgical resection.  The patient has requested coverage for transcatheter arterial chemoembolization (TACE) with drug eluting beads.  This patient has unresectable liver cancer, and there is a lack of available treatment options in this setting.  Per National Comprehensive Cancer Network guidelines, select patients with unresectable liver cancer, without significant extra-hepatic disease burden, should be considered for treatment with locoregional therapy.  There is adequate medical evidence to support the requested services in this patients case.  In this clinical setting, the requested transcatheter arterial chemoembolization (TACE) with drug eluting beads is likely to be superior over other available treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned

A 37-year-old male has requested past and future coverage for Xifaxan for treatment of his bloating, gas, and distention.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the medication at issue in this patients case.  The current medical evidence supports the use of Xifaxan in this clinical setting.  The efficacy of Xifaxan in treating non-constipated irritable bowel syndrome is well-documented in the peer-reviewed medical literature.  Xifaxan is considered by the gastroenterology community to represent a viable treatment option for this patient population.  Menees and colleagues conducted a meta-analysis and systematic review of available randomized, placebo-controlled trials evaluating the efficacy and tolerability of Xifaxan (rifaximin) in patients with irritable bowel syndrome.  The authors concluded that Xifaxan was more effective than placebo for global symptoms and bloating in patients with irritable bowel syndrome.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for residential treatment center services. The Health Plan has denied this request indicating the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. At issue in this case is whether the RTC services were medically necessary.The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, treaters score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. In this case, in terms of risk for self- harm, the records support a score of one due to a lack of current suicidal ideation and no self-harming behaviors. With regard to functional status, the records support a score of two due to some problems with comorbidity. In terms of medical, addictive and psychiatric comorbidity, the records support a score of two due to overall medical stability. Regarding level of stress of the recovery environment, the records support a score of one due to a stable living situation. For the level of support for the recovery environment, the records support a score of one due to family support and availability of treatment resources, but some difficulty in relationships with her family members. With respect to treatment and recovery history, the records support a score of three due to recent success at the residential treatment center level of care. Lastly, for engagement and recovery status, the records support a score of one. This is due to cooperation in treatment and insight into the need for treatment and her treatment needs. For a composite score of 10, CALOCUS indicates the appropriate level of care is treatment in a community-based outpatient clinic setting. Therefore, the RTC services at issue in this case were not medically necessary.Final Result: The reviewer determined that the services at issue were 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 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 enrollee is requesting authorization  coverage, and reimbursement, for mental health substance abuse partial hospitalization program (PHP) services. She entered a program for management of substance use disorder. The evaluating psychiatrist recommended starting low-dose Geodon for possible bipolar disorder. For risk of harm, the enrollees score is 3, due to binge behavior or excessive use of substances, resulting in potentially harmful behaviors without current involvement in such behavior. For functional status, the enrollees score is 3, due to significant disturbances in vegetative activities, such as sleep, eating habits, activity level, or sexual appetite, which do not pose a serious threat to health. The enrollee demonstrates significant deterioration in her ability to fulfill responsibilities and obligations to job, school, self, or significant others, and these may be avoided or neglected on some occasions. Chronic and/or variably severe deficits exist in interpersonal relationships, her ability to engage in socially constructive activities, and her ability to maintain responsibilities. For comorbidity, the enrollees score is 3, due to significant psychiatric symptoms and signs are present which are themselves somewhat debilitating, and which interact with and have an adverse affect on the course and severity of any co-existing substance use disorder. For recovery environment level of stress, the enrollees score is 3, due to a significant transition, causing disruption in life circumstances; such as job loss, legal difficulties or change of residence. There is danger in or near the habitat. There is easy exposure and access to alcohol and drug use. For recovery environment level of support, the enrollees score is 2, due supportive resources are not abundant, but are capable of and willing to provide significant aid in times of need. For treatment and recovery history, the enrollees score is 3, due to at least partial recovery has been maintained for moderate periods of time, but only with strong professional or peer support or in structured settings. For engagement and recovery status, the enrollees score is 2, due to the enrollee shows some recognition of her personal role in recovery and accepts some responsibility for it. The enrollees composite LOCUS score is 19, which correlates with high intensity community-based services. 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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for L3-4 laminectomy and foraminotomy with exploration and widening of decompression at L4-5 lumbar decompression (CPT 63047). Findings:  The physician reviewer found that the patient has a history of ongoing radiating lower extremity pain. Physical examination shows chronic changes in the left lower extremity, which is supported by a recent electromyography (EMG) study. However, the records provided for review do not include imaging reports documenting ongoing nerve compression to warrant additional decompressive surgery. The current medical literature supports revision decompression when a patients history, imaging, and physical examination findings demonstrate ongoing nerve compression (Martin, et al.; Berry, et al.). Overall, there is a lack of evidence of current nerve compression to support an indication for the requested laminectomy and foraminotomy and lumbar decompression. For these reasons, the requested L3-4 laminectomy and foraminotomy with exploration and widening of decompression at L4-5 lumbar decompression (CPT 63047) 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 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

A 49-year-old female enrollee requested authorization and coverage of a DEXA scan. The Health Plan denied the request indicating that the requested DEXA scan is not medically necessary for evaluation of the enrollee for possible osteoporosis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested DEXA scan is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of his hepatitis C. Findings:  The physician reviewer found that per 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, regardless of fibrosis, should be treated except those with limited life expectancy due to nonliver-related conditions. For treatment-experienced patients with genotype 6 hepatitis C, the guidelines recommend Harvoni for 12 weeks. This is based on both in vitro data and clinical trial results showing 96% sustained virologic response after 12 weeks of therapy. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for targeted therapy and radiation therapy. The National Comprehensive Cancer Network (NCCN) guidelines support the use of radiation therapy to relieve biliary obstruction from a hepatocellular mass. A course of palliative radiation therapy may be beneficial for this patient if she is able to tolerate the treatment. The goal of palliative radiation therapy would be to shrink the mass and relieve the patients biliary obstruction. This is a common indication for radiation therapy. All told, the requested targeted therapy and radiation therapy are 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 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: Experimental/Investigational
Decision: Overturned

 A female enrollee requested breast tomosynthesis for medical evaluation of her risk for breast cancer.  Findings:  Three physician reviewers found that literature does support the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate when used with standard mammographic imaging. Given these findings, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 37-year-old female enrollee has requested for Rituxan for treatment of her myasthenia gravis. Findings:  Three physician reviewers found that rituximab (Rituxan) is not a first line therapy for myasthenia gravis, several small studies have reported that Rituxan is efficacious in the treatment of this patient population. Specifically, the studies referenced above suggest that Rituxan has been beneficial in the treatment of myasthenia gravis, particularly in treatment resistant patients. In this particular case, the patient has failed multiple first line therapies for myasthenia gravis and has had to be hospitalized for her condition.  To this end, a trial of Rituxan is medically reasonable, as undertreated myasthenia is a potentially life threatening disease.