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

The parent of a four-year-old male enrollee has requested  for speech and language therapy, occupational therapy with sensory integration therapy and social skills group therapy for treatment of the enrollees autistic disorder. Findings:  Two physician reviewers found that Zachor and colleagues, early intervention can help the patient acquire skills for his daily living and decrease his dependence on others. Further delay with therapy will prolong the goals for acquisition of skills and may cause regression. Utilizing this patients interests in a global approach is medically indicated, as he is already in therapy and is showing some positive signs. Providing skills for this patient to take care of self help needs, communication and social well-being will enable him to fare better in his adult years.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old male enrollee has requested a referral to an infectious disease specialist for treatment of his soreness and pain.  Findings:  The physician reviewer found that the reviewed series of laboratory results demonstrate evidence of an inflammatory process including an elevated ESR and CRP that should be assessed. The patients positive Western Blot IgM may be falsely positive, but in the absence of any notes from providers, that cannot be assessed. Based on the available documentation, evaluation of the abnormal test results by a specialist in infectious diseases is appropriate. Therefore, the requested referral to an infectious disease specialist is 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 authorization and coverage for Zepatier 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, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including or Zepatier when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. The AASLD/IDSA guidelines also cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 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 mother of an eight-year-old male enrollee has requested an external insulin pump for him for the treatment of the enrollees diabetes. Findings:  The physician reviewer found that management of the enrollee's Type 1 Diabetes cannot be accomplished with insulin syringes.  The external insulin pump is able to provide insulin in 0.05 unit increments.  There is no alternative device available.  It is very important in children to avoid hypoglycemia, as they may not be able to recognize the symptoms of a decreasing blood glucose level.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old female enrollee has requested acupuncture for the treatment of her ulnar neuritis and medial epicondylitis. Findings:  The physician reviewer found that acupuncture is an oriental medicine technique that has been incorporated into Western medicine for management of several medical conditions. Review of the American College of Occupational and Environmental Medicine (ACOEM) guidelines reveals that acupuncture treatments are indicated for management of elbow, forearm, wrist, and hand complaints. The guidelines recommend treatment one to three times per week for an optimum duration of one to two months. Moreover, is it appropriate to extend acupuncture treatment if functional improvement is documented such as a clinically significant improvement in activities of daily living or a reduction in work restrictions, and a reduction in the dependency on continued medical treatment. This patient has experienced a 50% improvement in symptoms with acupuncture and has been able to avoid the need for more aggressive therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hydrogen breath testing for evaluation of the enrollees chronic diarrhea and weight loss. Findings:  The physician reviewers found that hydrogen breath testing is not likely to be more beneficial for treatment of the patients medical condition than available standard approaches. Symptom induction during a breath test has been found to correlate poorly with the presence of carbohydrate malabsorption. Breath hydrogen tests have limited clinical value in guiding clinical decision for a patient with a functional bowel disorder. In this case, the records noted that the patients symptoms were likely of multifactorial origin and listed a number of differentials to pursue as well as additional trials to consider. As such, hydrogen breath tests are not likely to assess for small intestinal bacterial overgrowth in this clinical setting. Therefore, hydrogen breath testing is not likely to be more effective than other methodologies for evaluating this patients medical condition. Final Result: Two of the three reviewers determined the requested services are 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 reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 21-year-old female enrollee has requested for inpatient mental health services for treatment of her behavioral health issues.  Findings:  The physician reviewer found that the patient was noted to show some thought disorder with psychosis such that the treating psychiatrist recommended treatment on an acute inpatient unit for safety purposes. This conclusion is consistent with the American Psychiatric Association (APA) treatment guidelines, which advocate in favor of therapy at the least restrictive level possible. Further, the appropriate treatment setting should provide the patient with the necessary support and supervision required for the patient to progress in functioning. The requested inpatient mental health treatment has been demonstrated to be medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 50-year-old female with multifocal breast cancer, which has been appropriately treated. She is of Dutch heritage and is the only child of her mother, who also was an only child who succumbed to breast cancer. The patients grandmother (mothers mother) also died of cancer, type unknown. The patient has four children. She has requested authorization and coverage for BRCA 1 and BRCA 2 genetic testing. The Health Plan has denied this request on the basis the requested genetic testing is not medically necessary in this clinical setting.This patient developed breast cancer at the age of 49. Even without a strong family history the patient qualifies for consideration of BRCA testing. Although testing will not impact the patients treatment, it may have a significant impact on the patients children and other family members. It is medically reasonable and appropriate for the patient to undergo the requested genetic testing as it will provide significant future value for her children. Based upon the information set forth above, I have determined the requested genetic testing is medically necessary. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dupixent 300mg/mL pre-filled syringe. The U.S. Food and Drug Administration approves the use of Dupixent for the treatment of atopic dermatitis. In a systematic review of systemic immunomodulatory treatments for patients with atopic dermatitis, the review concluded that dupilumab and cyclosporine may be more effective for up to 16 weeks of treatment than methotrexate and azathioprine. In this case, the documentation reflects that the patients condition has been present for several years and has been treated with topical steroids. Given current medical literature, and the patients persistent symptoms, the requested medication is medically indicated. Therefore, Dupixent 300mg/mL pre-filled syringe is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 19-year-old female enrollee requested authorization and coverage for gastric bypass surgery. The health plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees obesity with comorbid conditions including stress incontinence, chronic back pain, and amenorrhea.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 at this time.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 36-year-old male with chronic viral liver disease (hepatitis B virus) and HIV disease. While the patient was being treated with the current standard of care for his infection (pegylated interferon), he developed neutropenia, a known side effect of pegylated interferon therapy. The patients provider has recommended a course of Neupogen. The Health Plan has denied authorization and coverage for Neupogen on the basis it is not medically necessary for treatment of the patients medical condition.There are substantial data in the literature supporting the use of pegylated interferon as the best therapy for chronic hepatitis B. The use of any of the interferons is associated with a decrease in blood cell lines. As a result, the use of growth factor is occasionally required to allow continuation of therapy. The submitted records demonstrate the patients WBC counts did decrease to a potentially life-threatening level and did respond to WBC growth factor infusion. Thus, in order to allow the patient to complete his indicated interferon therapy WBC growth factor (Neupogen) is an appropriate and acceptable therapy. No other antiviral therapy has been successful. Neupogen will allow the patient to continue his indicated therapy. Therefore, 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: Medical Necessity
Decision: Upheld

The parent of a 12-year-old male enrollee has requested speech therapy at the frequency of two sessions per week for treatment of the enrollees autism.  Findings:  The physician reviewer found that this patient with a diagnosis of autism presents with limited intellectual skills as well as communicative, self-help, and sensory issues. Speech therapy is a standard modality for the treatment of autism. The patient has received ABA therapy for many years with one of the stated goals being the ability to make his needs known. Attempts to utilize a Picture Exchange system of communication have been unsuccessful. Although the patients prior attempts to develop verbal communication skills have not been successful, there is support in the medical literature for the continuation of speech therapy despite an individuals age and prior lack of response to therapy. In the case of this patient, the Health Plan has recommended one weekly session of speech therapy. This frequency of therapy is medically reasonable and appropriate. Two sessions of speech therapy per week are not likely to confer significant additional benefit over one session per week and therefore the requested frequency of two weekly speech therapy sessions is not medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for radiofrequency volumetric tissue reduction of the tongue procedure (CPT 41530)Findings:  Three of the three physician reviewers found the radiofrequency volumetric tissue reduction of the tongue procedure (CPT 41530) at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Sonsuwan  and colleagues report that radiofrequency ablation can be considered as the second-line treatment in patients with mild-to-moderate OSA. In this case, the patient has failed a trial of PAP and a mandibular repositioning appliance. The patient was a good candidate for radiofrequency ablation due to the mild nature of her obstructive sleep apnea (OSA), low body mass index (BMI), large tongue base, and failure of first-line therapy. Therefore, radiofrequency volumetric tissue reduction of the tongue procedure (CPT 41530) was likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that service at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with sub-specialty certification in sleep medicine and is actively practicing. Physician reviewers 2 and 3 are board certified in otolaryngology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyaluronan injections. Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting. This patient presents with significant chronic bilateral knee pain. Functional limitations are noted in walking tolerance due to knee pain. Clinical examination findings are consistent with x-ray evidence of bilateral knee medial compartment osteoarthritis. Reasonable conservative treatment, including medications, activity modification, and exercise, have failed to provide adequate symptom relief. She has undergone two previous series of Hyalgan injections for the right knee, with pain reduction and functional improvement documented for at least six months. She desires to delay total knee replacement surgery. Evidence-based literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Therefore, hyaluronan injections are medically necessary for the 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 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 51-year-old male enrollee has requested an anterior lumbar interbody fusion for the treatment of his discogenic low back pain. Findings:  The physician reviewer found that the patient has failed conservative treatment. Continued attempts at conservative management are not likely to be effective. Surgical treatment is indicated for this patient. Anterior lumbar interbody fusion is medically appropriate for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for human recombinant growth hormone treatment medication Genotropin for treatment of the enrollees growth deficiency. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. A review of the growth curve shows the patients height between the 10th and 25th percentile. The patient was diagnosed with Crohns disease. It is not clear when the therapy for that condition was initiated, but it appears from the curve that GH was introduced at age 14 and a few months. There is some evidence at this growth curve for already some resumption of normal growth prior to the initiation of exogenous GH. The genetic target for this family is 68.5 inches (+/- ) 4 inches to 95% confidence. As such, any adult height above 64.5 inches would be normal for this familial context. Moreover, the patients bone age was consistent with that of a 14 year old. This bone age provides a predictive adult height to be around 66 inches, which would be considered normal for this genetic target. Therefore, the patients adult predicted height is not short enough to warrant growth hormone treatment on the basis of idiopathic short stature. The definition is commonly considered to be a height more than two standard deviations below the corresponding mean height for a given age, sex and population, in whom no identifiable disorder is present. Based on this patients record, he does not have evidence of growth hormone deficiency. The patients growth factors were both normal and the patient did not have any discernible bone age delay. Additionally, this data does not support a discernible growth retardation from the Crohns disease itself. 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 pediatrics with sub-specialty certification in pediatric endocrinology 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: An enrollee has requested authorization and coverage for hydrocortisone butyrate 0.1% ointment for treatment of the enrollees psoriasis. Findings:  The physician reviewer found that Review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The patient presents with history of psoriasis affecting the face. The patient is requesting hydrocortisone butyrate 0.1% ointment.  The Health Plan has denied the request as the requested medication is non-formulary and has authorized hydrocortisone 2.5% topical cream. The patient indicates that treatment with hydrocortisone 2.5% topical cream is not as effective as hydrocortisone butyrate 0.1%. However, there are other formulary options for treatment of the patients medical condition within the same steroid potency class as hydrocortisone butyrate 0.1% ointment. The records submitted for review do not demonstrate that the patient has not tried these agents. Moreover, while long-term use of mid-potency topical steroids on the face is best avoided due to potential side effects, approval of hydrocortisone butyrate 0.1% ointment does not avoid those implications. All told, the request for hydrocortisone butyrate 0.1% ointment has not been established as medically necessary for treatment of the 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing. Findings:  The physician reviewer found that based on the review of the current medical literature, advanced lipoprotein testing is not definitively demonstrated to be more beneficial than the standard laboratory tests for patients in this clinical setting. There is a lack of evidence to support that advanced lipoprotein testing improves a patients health outcomes when compared to standard lipid testing. In addition, in this patients case, the medical records provided for review do not indicate how the ordering provider intended to use the data obtained or how it would be used to affect treatment or reduce cardiovascular risk. The provider would have been able to base treatment options by using a standard lipid profile alone. A standard lipid testing includes total cholesterol, low density lipoprotein, high density lipoprotein, and triglyceride levels. In sum, the advanced lipoprotein testing was not likely to have been more effective than the other available methods of for the evaluation of this patient.  Final Result: All three 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: Physician reviewers 1,2 & 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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.