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

A 29-year-old female enrollee has requested residential treatment center (RTC) level of care services for her behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, this patient has a long history of bulimia nervosa. She was placed in the residential treatment facility due to apparent out of control eating behavior. Applying the American Psychiatric Association (APA) treatment guidelines for patients with eating disorders, as of the said date this patient was no longer showing signs or symptoms which would require the residential level of care. The treatment records indicate the patients eating disorder was much improved to the point where she required very little intervention and could have been transitioned to a less restrictive treatment environment. Overall, she did not require the supervision and direction provided in a residential treatment facility during the period under review and there is no documentation in the treatment notes that the patient was likely to relapse with a lesser level of care during this timeframe.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for physical therapy services. The submitted documentation fails to demonstrate the medical necessity of the requested services. Close therapist supervision and guidance can be important in the initial stages of a rehabilitation program for shoulder symptoms due to rotator cuff tears. However, long-term skilled physical therapy, including supervised exercises, modalities and formal manual therapies/modalities, is not of proven benefit in this clinical scenario. As range of motion and strength are restored and the patient becomes accustomed to the exercises, the program can be transitioned to an independent program. In this case, although the patient has persistent symptoms, further physical therapy would not reasonably be expected to favorably impact the clinical or functional outcomes or course. The records do not support the medical necessity of additional skilled exercise supervision. There is a lack of proven marginally significant benefit of formal manual therapy or other formal passive palliative modalities over palliative measures that can be applied independently. All told, the requested physical therapy services 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 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 seven-year-old female with a diagnosis of autism and developmental delay who has been receiving therapy since February 2002. Additionally, the patient has received Lovas therapy eight hours per week and participates in a weekly playgroup as well as a special day class. The patients speech therapist documented receptive speech at 28 months in the 2002 evaluation and at 30 months in the 2004 evaluation. Expressive language skills were documented at 16 months in 2002 and 28 months in 2004. Behavioral/pragmatic language skills assessment documented improvement in tolerance during sessions from 15 minutes to 30 minutes. The submitted records do not discuss pragmatic language in a social setting. The patients therapist has recommended two hours per week of speech therapy. The Health Plan indicates the patients records do not demonstrate speech therapy from 1/7/03 to 7/26/04 was medically necessary. Therefore, the Health Plan has denied reimbursement for these services.In reviewing the available progress reports and session notes it appears the patient has achieved little progress during the period at issue. It could be argued the few documented gains are related to maturity. The objective testing provided for expressive and receptive speech demonstrate minimal gains over a two-year period. The improved attention to task could also be attributed to maturity. Little evidence has been provided that pragmatic communication skills have improved. Furthermore, objective standardized test results have not been provided to document improvement in communication skills. As such, there is insufficient evidence demonstrating speech therapy was medically warranted in this case.Based upon the information set forth above, I have determined that the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 47-year-old male with a long-standing history of neck and back pain. He participated in a computer-assisted strengthening/exercise program from September 2003 through July 2004. The patient has requested authorization and coverage for continued therapy. The Health Plan has determined the requested therapy is not medically necessary for treatment of the patients neck and back pain.Review of the submitted treatment notes indicates the patient has been using machines with computer assist to perform spinal kinetic activity. However, the submitted notes do not document a program requiring skilled therapist intervention. There is no documentation in the peer-reviewed literature, which demonstrates a computer-assisted exercise program produces superior or equal results to a self-paced gym program with weight machines. Hence, there is no evidence the requested therapy is medically necessary. Therefore, I have determined that the requested therapy is not medically necessary for the treatment of the patients medical condition. 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 combination therapy of Erbitux and Votrient (pazopanib). As noted in the medical literature, there are limited proven therapies for the treatment of metastatic squamous cell cancer of the urethra. Various agents have been studied in the clinical trials and are consistent with this patients prior systemic therapies. Erbitux is a monoclonal antibody, which has been U.S. Food and Drug Administration (FDA) approved for use in metastatic colon cancer, and along with radiation therapy for squamous cell head and neck cancers. Votrient is FDA approved for use in soft tissue sarcomas, renal cell carcinoma, gastrointestinal stromal tumors, and certain thyroid cancers. Since there is a lack of data to support the use of this combination therapy in this patients squamous cell urethral cancer, the requested combination therapy of Erbitux (cetuximab)  and Votrient (pazopanib) is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested combination therapy 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 medical 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

A 54-year-old male has requested coverage for Gilenya for treatment of his multiple sclerosis.  Findings:  The physician reviewer found that this patient has multiple sclerosis, and he has been on disease-modifying therapy. Treatment with Avonex was limited by side effects and inadequate efficacy, and treatment with Tysabri was limited by increased progressive multifocal leukoencephalopathy risk associated with prolonged therapy and positive JC viral titers. Patient compliance is important in long-term therapeutics. In general, patients prefer oral treatments and are more likely to be compliant with oral treatment, when compared to injectable therapies.  Gilenya has been studied and found to be effective as oral therapy. The requested medication is an effective treatment for patients with relapsing forms of multiple sclerosis to reduce the frequency of clinical exacerbations.  A comparison study by McDonagh showed that for patients with relapsing-remitting multiple sclerosis, Gilenya 0.5mg and 1.25mg once daily were superior to interferon beta-1a in improving relapse-related outcomes over a one-year period.  Patient preference for non-injection therapy is medically relevant, as adherence to treatment is likely to be better.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the abdomen and pelvis. Abdominal pain is a common clinical presentation. The American College of Radiology (ACR) Appropriateness Criteria serves as general guidelines for various clinical presentations. The specific imaging study recommended for abdominal pain is based on pain location.  Ultrasonography is recommended to assess right upper quadrant pain, and computed tomography (CT) is recommended for right and left lower quadrant pain. In the setting of acute pain, MRI is generally not thought of as a first-line or even second-line approach. There are specific clinical presentations where MRI is indicated, such as patients who are pregnant or patients in whom a CT scan is indeterminate. However, for the most part, MRI is not as optimal as ultrasound and CT scanning. The ACR has also established criteria for the evaluation of vaginal bleeding. Based on the criteria, MRI was not indicated for the evaluation of this patients vaginal bleeding. MRI of the female pelvis is generally reserved for cases when the ultrasound findings are not definitive. On occasion, MRI will better define fibroids and will help confirm the diagnosis of adenomyosis. But for the most part, ultrasonography is sufficient to make these diagnoses. In sum, the medical evidence does not support MRI in this clinical setting. Considering the history of pancreatitis, a CT scan would have been appropriate.  Additionally, in the setting of simple vaginal bleeding, an MRI study is generally not performed. Thus, MRI of the abdomen and pelvis was not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 authorization and coverage for Zepatier for 12 weeks for treatment of the enrollees hepatitis C. Findings: The physician reviewer found 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. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier for 12 weeks 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. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Zepatier for 12 weeks is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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

A 45-year-old male enrollee has requested authorization and coverage for a neurosurgical consultation for treatment of the enrollees cervical intervertebral disc disease. Findings:  The physician reviewer found that the requested services are not medically necessary in this patients case at this time.  The initial management of patients with neck pain and evidence of infection or significant neurologic deficit, such as weakness or myelopathy, is an urgent referral.  In the absence of these signs, patients should be prescribed activity modification, analgesics, non-steroidal anti-inflammatory medications (NSAIDs), physiotherapy, cervical traction, and/or education.  If symptoms persist or worsen despite these conservative measures, a referral to a neurosurgeon may then be warranted.  In this patients case, the medical records do not reveal any documentation of infection or myelopathy.  There is mention of an electromyography report showing a C7 radiculopathy.  However, a motor examination of the C7 innervated muscles is not documented.  Thus, the clinical significance of the electromyography findings is unclear.  Although the patient reported that he has tried three weeks of anti-inflammatory treatment and six weeks of activity modification, there is no documentation of such in the submitted medical records.  Based on the available medical records, the requested neurosurgical consultation is not medically indicated for the treatment of this patient at this time.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested an additional 12-week course of Harvoni for medical treatment of his hepatitis C virus.  Findings:  Two physician reviewers 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), treatment with Harvoni for 24 weeks is recommended for patients with Child-Turcotte-Pugh class B cirrhosis, and the provided records indicate the patient meets these criteria. Based on the evidence of safety and efficacy in the published literature, and clinical guidelines, the treatment of Harvoni for 24 weeks is medically necessary in this case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Otezla 30 mg at a quantity of 60 pills per month. Review of the submitted clinical documentation does not support the medical necessity of Otezla 30 mg at a quantity of 60 pills per month. Given the patients co-morbidities, the use of methotrexate or cyclosporine is best avoided due to her history of liver and kidney issues. However, based upon the documentation provided, the patient has not attempted treatment with Enbrel, Humira or Cosentyx. The efficacy of these alternative medications has been sufficiently established in this setting and it is anticipated they are likely to be more effective than the requested Otezla. Furthermore, the patients co-morbidities do not preclude the use of these preferred systemic agents. As there is no contraindication or documented history of adverse effects from treatment with the preferred agents which are U.S. Food and Drug Administration (FDA) approved for this patients medical condition, the requested Otezla 30 mg at a quantity of 60 pills per month is not medically necessary. Final Result: The reviewer determined that the requested medication regimen 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: Medical Necessity
Decision: Upheld

A 62-year-old female has requested for the medication Lyrica for treatment of her idiopathic sensory neuropathy.   Findings:  The physician reviewer found that lyrica is currently FDA approved and has demonstrated efficacy and safety in the peer-reviewed literature for neuropathic pain due to diabetes and post herpetic neuralgia, but not for idiopathic sensory neuropathies. There is no evidence to indicate the patient has undergone trials of other neuropathic medications that have been utilized for longer periods of time and have a history of efficacy and safety for idiopathic sensory neuropathic pain/sensations.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orgain Kids nutritional shakes. The Health Plan has denied this request indicating that the requested oral formula is not medically necessary for treatment of the enrollee who has a history of diffuse leukomalacia.Findings: The submitted documentation does not support the medical necessity of the requested oral formula. The patients symptoms of gagging and vomiting are multifactorial. Contributors to these symptoms include aspiration, constipation, baclofen use, and episodes of dysmotility, in addition to a possible sensitivity to PediaSure.  The parents have requested an organic nutritional shakes. The records do not indicate that this patient has tried a conventional soy free formula. Additionally, the medical literature is unclear as to the affect organic food has on human health. Overall, there are limited studies on the risk of nausea with organic versus conventional formulas. In addition, there is a lack of medical evidence to support that the Orgain Kids nutritional shake has a beneficial health effect for all conditions. For these reasons, the medical necessity for Orgain Kids nutritional shakes have not been demonstrated for the treatment of this patients medical condition.Final Result: The reviewer determined that the requested oral formula 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 pediatric gastroenterology with expertise in pediatric nutrition 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 45-year-old female enrollee has requested a CT scan of the abdomen for an evaluation of her abdominal pain. Findings:  The physician reviewer found that this patient has chronic diarrhea that is sometimes associated with cramping. She had no abnormal physical findings. There is no documentation of other imaging studies, such as a small bowel study or ultrasound.  Review of the peer-reviewed literature found no articles to support the use of CT scan of the abdomen in this clinical situation. CT scans of the abdomen are useful to evaluate for abnormalities of the liver, kidneys and pancreas, to evaluate an abnormality found on physical examination or on another imaging study, or to evaluate for suspected cancer. Patients with chronic pancreatitis usually have other symptoms, such as pain, and may have abnormal pancreatic enzyme levels on blood work. Diarrhea from chronic pancreatitis can occur when there is associated malabsorption. Patients in this case usually also have weight loss. There were no documented reports of weight loss in this patient. All told, there was no clinical indication for a CT scan of the abdomen in this particular setting.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested lumbar sympathectomy for treatment of the enrollees medical condition.  Findings:  Two physician reviewers found that there is sufficient support for the requested services in this clinical setting.  There is a lack of other options other than the lumbar sympathectomy in this patients case.  Per the medical evidence, a lumbar sympathectomy is the best surgical treatment option. This patient has failed treatment with medication, and he continues to have symptoms which affect his quality of life.  In sum, the requested lumbar sympathectomy is likely to be of greater benefit than other treatment options. Final Result: Two 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:  All three reviewers are board certified in 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested authorization and coverage for Nutropin AQ Nuspin. The records provided for review do not establish the medical necessity of the requested GH therapy for treatment of this patients short stature. The documentation suggests that this patients height, pre-treatment growth velocity, and bone age are normal. Further, the patients predicted adult height is within two standard deviations of his target height and normal for U.S. adult males. In addition, his pre-treatment growth factors were appropriate for his bone age and he has no known morphological abnormalities of the pituitary gland or midline structures. All told, the requested Nutropin AQ Nuspin is not supported as medically necessary for treatment of this patients short stature.  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 subspecialty 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.