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 pelvic floor program consisting of (rectal balloon biofeedback therapy) three times a day for one week, and twice a day for a second week. The records document that this patient presents with pelvic dyssynergia and possible anal fistula. Treatment has included surgery, but the patient reports continued symptoms. As noted in the medical literature, symptomatic constipation, anorectal inflammation, and pelvic dyssynergia may require surgery when scarring renders Botox and pelvic floor therapy ineffective. Once diagnostic evaluation reveals no anatomic impediment to biofeedback and medical management, this is considered the mainstay of treatment for this patient population. Mazor and colleagues assessed 138 patients with chronic constipation and symptoms of functional defecatory disorder who were treated with biofeedback. The authors concluded that following biofeedback, 89% of patients in the high group reduced their rectal pressure to normal. Parker and colleagues found that the overall response rate with biofeedback in patients with chronic constipation and fecal incontinence secondary to pelvic floor neuromuscular sensory or motor dysfunction was 76.2%. Given this support, the requested pelvic floor program consisting of (rectal balloon biofeedback therapy) three times a day for one week, and twice a day for a second week is 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 urology 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 reimbursement for Orthovisc injection series for the right knee, and prospective authorization and coverage for Orthovisc injection series for the right knee.At issue in this case is whether the Orthovisc injection series for the right knee provided on specific dates and during a specific future period were and are medically necessary to treat the patients medical condition. An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. 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, there is a history with viscosupplementation. Furthermore, the options are limited. The patient has tried and failed other treatments. Therefore, the Orthovisc injection series for the right knee provided on specific dates was medically necessary for the treatment of the patients medical condition. Additionally, the requested Orthovisc injection series for the right knee during a specific future period is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were and 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Viekira Pak for treatment of his hepatitis C.  Two physician reviewers found that there is sufficient support for the requested medication in this clinical setting.  Per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  The medical evidence supports treatment of all patients with hepatitis C, except those with limited life expectancy due to non-liver-related comorbid conditions.  If the infection is left untreated, it can lead to a variety of systemic complications such as renal disease and vasculitis, in addition to causing ongoing hepatic damage with further progression of fibrosis to cirrhosis.  Therefore, the requested Viekira Pak is medically indicated for the treatment of this patient.  Final Result: Two reviewers 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: 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

The parent of a 19-month-old female enrollee has requested health services for weekly blood pressure monitoring for evaluation of the enrollees hypertension.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  This patient has angiopathy that has resulted in strokes as well as renal artery stenosis, and sequelae include hypertension and hemiparesis. In addition, she has significant gastrointestinal abnormalities. Given the clinical presentation of this patients underlying medical condition, and the potential for additional significant morbidity, it is necessary to continue weekly blood pressure monitoring.  Hypertension in combination with vascular abnormality increases potential for complications, such as further stroke.  In this patients case, it is not medically appropriate to require the family to present to the pediatricians office weekly for blood pressure monitoring given her medical condition.  All told, home health visit services for weekly blood pressure monitoring are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Myrbetriq for treatment of the enrollees overactive bladder. Findings: The physician reviewer found that the records indicate that this patient has a diagnosis of overactive bladder. Anticholinergic medications are first-line therapy for management of this medical condition. Myrbetriq is a beta 3 agonist which relaxes the bladder by a mechanism which is different than anticholinergic medication. The patient has tried and responded to Myrbetriq. In phase III clinical trials, Myrbetriq at daily doses of 25, 50, and 100 mg demonstrated significant efficacy in treating symptoms of overactive bladder. Results have been maintained for up to one year in some studies. However, the current medical literature has not demonstrated better efficacy of Myrbetriq over anticholinergic therapy for treatment of overactive bladder in head to head trials. Hence, treatment with Myrbetriq is not medically necessary for 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 urology 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 and prospective authorization and coverage for (1) PHP level of care and (2) future PHP level of care. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers 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. With regard to risk of harm, the records support a score of 3. The patient had a moderate risk of harm, due to the presence of suicidal ideation and struggles with sticking to her meal plan and exercising excessively. In terms of functional status, the records support a score of 3. The documentation showed moderate impairment due to her disordered eating, depression, and anxiety affecting her physical health, resulting in her taking two quarters off from graduate school. With regard to comorbidity, the records support a score of 3. The records documented the presence of tachycardia and weight loss due to the patients disordered eating.In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a mildly stressful environment due to disruptions in her life caused by the pandemic.With regard to level of support of the recovery environment, the records support a score of 2 as the patient identified friends and family who could support her recovery efforts. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment, reporting persistent disordered eating despite several admissions at varying levels of care over the past several years.With regard to treatment acceptance and engagement, the records support a score of 3. The patient expressed motivation to change, although she struggled with adhering to her eating plan and limiting exercise outside of the treatment setting. Thus, the patient had a total score of 21. In this case, the recommended level of care is Level 4, medically monitored non-residential care. Therefore, (1) PHP level of and (2) future PHP level of care was and is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 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

A 55-year-old female enrollee has requested for molecular testing for evaluation of her non-small cell lung cancer.  Findings:  The physician reviewer found that the molecular testing, there is no current clinical justification for the utility of such testing, including the EGFR mutation and ALK fusion gene, done in lung cancer. Should the patient exhibit a recurrence, then these tests are routine, and should be done if she has further recurrence that can be biopsied. There is no real relevance in the outcome unless the patient has recurrent cancer that needs to be treated. As such, the requested molecular testing has not been demonstrated to be medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

The representative of a 10-year-old female enrollee requested authorization and coverage of vision therapy for the treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested therapy is not medically necessary for the treatment of the enrollees vision problems.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for urogynecologist consultation. The submitted documentation supports the medical necessity of the requested services. This patient presents with mild symptoms consistent with pelvic floor weakness and prolapse. Her clinical presentation is not one typically seen with this disease. She does not have typical risk factors for prolapse. In this patients case, she is likely to achieve benefit from conservative medical management of her prolapse. The management of uterine prolapse depends on the degree of prolapse and the resultant increase in patient symptoms. Per the records, the degree of prolapse is a combination of early stage change, grade one and grade two prolapse. When the symptoms are mild and the degree of prolapse is grade one, the patient may benefit from conservative measures, such as pelvic floor training. Additionally, a variety of different pessaries can be fitted and tried. In this patients case, evaluation with a urogynecologist is medically appropriate for further evaluation and treatment. Therefore, the requested urogynecologist consultation is 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 obstetrics and gynecology 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 63-year-old man who underwent radiation treatment for cancer of the left aryepiglottic fold and arytenoid squamous cell carcinoma. The radiation dose was 6600 Gy fraction. Treatment may have included portions of the tooth-bearing mandible. Post radiation the patient had extensive dental caries; he underwent full mouth extractions and alveoloplasty including excision of mandibular tori.  The patient received prophylactic hyperbaric oxygen therapy 20 dives pre-operatively and 10 dives post-operatively according to the Marx protocol. The patient recovered well from oral surgery. A request has been made for reimbursement for the hyperbaric oxygen therapy. The Health Plan has denied this request indicating the therapy at issue was not medically necessary.There is no evidence-based indication for prophylactic use of hyperbaric oxygen for management of routine dental alveolar surgery in the maxillo and mandible to prevent osteoradionecrosis. The Marx protocol was proposed in 1970 for patients receiving greater than 6800 Gy to the tooth bearing areas. It appears this patient received less than 6800 Gy. In any event, the efficacy of hyperbaric oxygen for osteoradionecrosis prophylaxis in routine oral surgery has not been established at this time. Thus, the use of hyperbaric oxygen in this clinical setting was not medically warranted.Based upon the information set forth above, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested a Quantum Q6 Edge power wheelchair for medical treatment of her quadriplegic cerebral palsy.  Findings:  The physician reviewer found that  Livingstone and Paleg studied the use of power mobility in children with cerebral palsy and found that Without efficient, independent mobility, young children are at risk of developing passive, dependent behavior and older children are at risk of decreased participation and isolation. In this case, the patient has very limited mobility and is fully dependent on other people for movement. She has demonstrated that she can safely use a power wheelchair. As such, a power wheelchair is reasonable and medically necessary for functional mobility. Based on the medical literature and documentation submitted for review, the request for the Quantum Q6 Edge power wheelchair is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 27-year-old female enrollee requested authorization and coverage of a referral to an otolaryngologist. The Health Plan denied the request indicating that the requested referral is not medically necessary for evaluation and treatment of the enrollees deviated septum and associated airway disorder.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested referral is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The mother of a seven-year-old male enrollee requested authorization and coverage of additional speech therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees autism.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old female enrollee has requested intramuscular (IM) antibiotic treatment using Rocephin for treatment of her medical condition.  Findings:  Three physician reviewers found that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient presents with nonspecific complaints with the medical records indicating that the patient was diagnosed with Lyme disease and previously treated with IV antibiotics. However, the specifics of her presentation at that time, confirmatory testing and the dosing of medication are not provided. The patients current presenting complaints are nonspecific and do not evidence that she is suffering from Lyme infection. Moreover, there is no historical or physical exam evidence documented in the medical records to support a diagnosis of Lyme disease. In addition, there is no laboratory testing documented to support a diagnosis of Lyme disease. Finally, intramuscular antibiotics are not recommended for the treatment of Lyme disease. Thus, the request for intramuscular (IM) antibiotic treatment using Rocephin is not likely to be more beneficial treatment than standard medical therapy in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus (HCV).  Findings:  The physician reviewer found that per the nationally recognized treatment guidelines there are several options with similar efficacy recommended for treatment-naive patients with HCV genotype 1a infection. Daily Harvoni for 12 weeks (Class I, Level A), daily Viekira Pak and weight-based ribavirin for 12 weeks (no cirrhosis) or 24 weeks (cirrhosis) (Class I, Level A) and daily Sovaldi plus Olysio with or without weight-based ribavirin for 12 weeks (no cirrhosis) or 24 weeks (cirrhosis) (Class IIa, Level B). The Health Plans formulary option of Viekira Pak and ribavirin is equally efficacious and as highly recommended per the medical guidelines as is the requested Harvoni. In this patients case, the documentation submitted for review does not support an absolute contraindication of the use of the Health Plans formulary of Viekira Pak and ribavirin. As such, the request for Harvoni is not medically necessary given the Health Plans authorization of Viekira Pak for treatment of the patients HCV which has identical rating and equivalent efficacy per the medical guidelines. 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 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

This patient is a 78-year-old female who is requesting a surveillance colonoscopy. She has a history of prior colonoscopies. Polyps were apparently found on those exams. She also reports a significant family history of colon cancer. The Health Plan has determined a colonoscopy is not medically necessary for evaluation of the patients medical condition.The patients family history is irrelevant as she already has undergone a screening exam at least once if not twice in the last ten years and was not found to have cancer. What are determinative in this case are the findings of prior examinations, (i.e., if adenomatous polyps were present on prior exams, and if so, the size and number of lesions present). These results will determine the appropriate follow-up interval. If adenomas were found on the patients last exam, a follow-up exam five years later is warranted as long as the exam was a high-quality study and the patients general health supports further surveillance. If no adenomatous polyps have ever been detected then no further screening for colorectal neoplasia may be needed (or at least not for ten years) as the patient had no neoplasia by age 74 and the likelihood of development of neoplasia that will affect her in her lifetime is remote. Therefore, I have determined that the requested colonoscopy is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.