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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested inpatient mental health services for treatment of her psychosis with mood disturbance.   Findings:  The physician reviewer found that although the patients illness was chronic, the record indicates a well-defined episode of symptom exacerbation. The patient endorsed vague suicidal ideation to the nursing staff because she believed she was possessed.  She noted a decreased need for sleep and a more powerful controlling entity. Her antipsychotic medication was changed and thereafter, she remained symptomatic, but evidenced a slow, yet incomplete recovery. The clinical documentation addressed the level of care needed to treat the patient and demonstrated the presence of an acute psychiatric syndrome during the entire hospital stay. Overall, the admission facilitated active treatment for a health related issue that was reasonably expected to improve the patients quality of life and functionality. Moreover, this treatment necessitated the expertise of well-trained mental health professionals. Both the clinical care and treatment setting were safe, appropriate and consistent with current American Psychiatric Association (APA) treatment guidelines. Thus, the inpatient mental health services were medically necessary for treatment of the patients behavioral health condition. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  The reviewer is board certified in 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: Overturned

A 30-year-old male enrollee has requested for brachial plexus surgery for treatment of her left brachial plexopathy and neuropathic pain.  Findings:  The physician reviewer found that adult brachial plexus reconstruction remains a dilemma to the reconstructive microsurgeon, especially when attempting to reconstruct cases of total root avulsion. A significant improvement in results has been achieved by a better understanding of various methods of reconstruction and prolonged postoperative rehabilitation. In the medical literature, Chuang concluded that brachial plexus surgery, consisting of primary nerve and late palliative reconstruction, is now a worthy surgical pursuit that makes a useless limb useful. For these reasons, the medical necessity of the requested surgery has been established in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five year old male enrollee has requested speech and language therapy services for the treatment of the enrollees autism. Findings:  Two physician reviewers found that children with autism have deficits in speech and language, as well as social communication. Therapists with experience working with children on the spectrum, handling the myriad of communication challenges that face these children, are most appropriate. Deficits in communication are integral to the diagnosis of autism, and are the foundation for many of the clinical findings. In the case of this patient, the history of chronic otitis media may have added to his deficits. The sooner and more aggressively these deficits are targeted, the better chance the patient has for developing adequate skills to function in the community. Speech and language therapy is therefore medically necessary and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus. Findings: The physician reviewer found that according to the 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 applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with a viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. In addition, guidelines cite data showing reduced survival with delayed treatment. For these reasons, Harvoni has been established as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The 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: 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: Experimental/Investigational
Decision: Upheld

A 37-year-old female enrollee requested authorization and coverage of IVIG intravenous immunoglobulin with an out-of-network Immunologist for the treatment of recurrent miscarriages. The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that IVIG intravenous immunoglobulin is not likely to be more beneficial for treatment of the enrollees recurrent miscarriages than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha Sureclick 140 mg/ml subcutaneous pen injector for treatment of the enrollee who has a history of carotid stenosis and coronary heart disease.  Findings:  The physician reviewer found that the documentation provided does not support the requested medication in this patients case. Based on the records provided, the patient has documented coronary vascular disease. There is no confirmed intolerance to statin medications in the documentation since there is no documented elevated muscle enzymes, elevated liver enzymes or transient worsening symptoms while on statins. In addition, the patients weakness may be due to his confirmed diagnosis of inclusion body myositis.  Moreover, there is no documented trial or intolerance of Zetia, a nonstatin medication that has been demonstrated to improve cardiac outcomes in patients with documented coronary disease. Additionally, there is no documented history of heterozygous or homozygous familial hyperlipidemia. Therefore, based on the records provided Repatha Sureclick 140 mg/ml subcutaneous pen injector is not medically necessary for treatment of this 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 internal medicine with sub-specialty certification in cardiovascular disease 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 57-year-old male enrollee has requested a color doppler transrectal ultrasound for an evaluation of his prostate cancer.  Findings:  The physician reviewer found that this test was necessary in this case to determine if there was pubic arch interference which would preclude use of brachytherapy.  As this patient has a high risk prostate cancer, brachytherapy was recommended as part of his treatment.  Therefore, the ultrasound was necessary to assist in determining the patients treatment plan. Specifically, the disputed procedure was medically necessary to determine the feasibility of brachytherapy.
Appeal type: Medical Necessity
Decision: Upheld

A 59 year-old female enrollee has requested the medication Sutent 25 mg for treatment of her uveal melanoma.  Findings:  The physician reviewer found that this patient has a rare disease, ocular melanoma, with sparse data in terms of clinical studies in the medical literature. Flaherty and colleagues reported on one series of patients with metastatic uveal melanoma. The authors found poor outcomes once uveal melanoma metastasized, thus they concluded that prevention of metastasis is optimal. To achieve this goal, adjuvant therapy has been utilized in well selected patients. In contrast to cutaneous melanoma, the ocular tumors have a high rate of KIT mutations making this an attractive target with tyrosine kinase inhibitors, such as Sutent. The abstract cited by the treating oncologist presents Sutent use in stage IV patients and the results only document 2 partial remissions and 12 patients with stable disease. While this cohort with hepatic metastases has a very poor prognosis and may not be an accurate depiction of Sutents potential, there is a lack of other outcome data from IRB-approved clinical trials documenting beneficial results in patients without metastatic disease. All told, there is inadequate published data to support the use of Sutent in this particular setting. As such, the medical necessity of Sutent as adjuvant therapy for this patient has not been established.
Appeal type: Medical Necessity
Decision: Overturned

A 19-year-old female enrollee has requested Lyrica for the treatment of her neuropathic pain. Findings:  The physician reviewer found that the patient has chronic neuropathic pain and first-line therapies have been tried and have failed. The safety of Lyrica has been sufficiently tested in other clinical applications and it was found to be safe at doses up to 300 mg twice per day. Painful diabetic peripheral neuropathy (DPN) is a model for a variety of other neuropathies. Historically, medications that are helpful for DPN are also helpful for other peripheral neuropathic pain syndromes. In fact, treatment with Lyrica is fast becoming the standard of care for neurologists and pain specialists in situations such as this one. It is not surprising that the patient has shown a measurable response to Lyrica, and continued treatment is medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old male enrollee has requested authorization and coverage for radiosurgery via CyberKnife for treatment of the enrollees acoustic neuroma. Findings:  The physician reviewer found that stereotactic radiosurgery has become a well-established treatment modality in the management of selected patients with acoustic neuromas. According to German, et al., among neurotologists, 42% perform stereotactic radiosurgery (approximately 58% of those use Gamma Knife, and 44% use CyberKnife) and 37% percent of patients seen by neurotologists receive radiation. Results are better than with those obtained using whole-brain radiotherapy and comparable to the best selected surgery-radiation series. However, review of the relevant peer-reviewed evidence does not reveal adequate data that CyberKnife is superior to conventional radiosurgery in this setting. Although this patient requires radiosurgery to treat this acoustic neuroma, the relevant scientific literature does not demonstrate that treatment with CyberKnife is superior to traditional radiosurgery in this setting. Conventional radiosurgery is medically appropriate and indicated to treat this patients condition. Therefore, while the patient should be treated with radiosurgery, the Health Plans denial for the use of CyberKnife is appropriate, as it is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 53-year-old male enrollee has requested  osteochondral talus autograft for treatment of his left talar central medial osteochondral lesion and idiopathic thrombocytopenic purpura.   Findings:  Two physician reviewers found that recent clinical studies have shown favorable midterm results in terms of improved pain and functional scores after osteochondral allografts of the talus. Based on the available scientific evidence, the use of osteochondral talus autograft in treating this patients talar central medial osteochondral lesion was likely to have provided the patient with a superior outcome when compared to standard alternatives including ankle fusion or arthroplasty. Thus, the services at issue were likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 33-year-old male enrollee has requested for a duodenal switch procedure for treatment of his morbid obesity. Findings:  The physician reviewer found that the duodenal switch procedure is an appropriate surgical option that is approved by the American Society for Metabolic and Bariatric Surgery (ASMBS), the Society of American Gastrointestinal Endoscopic Surgeons and the American College of Surgeons based on sufficient scientific evidence.  Like all operations, the duodenal switch procedure has its own set of particular risks and benefits, but has been attributed with the greatest amount of weight loss when compared to purely restrictive operations or hybrid operations such as the Roux-en-Y gastric bypass.  This patient needs to lose over 200 pounds to improve his health.  The duodenal switch procedure is an appropriate surgical option for this patient who otherwise has no metabolic, dietary or psychological barriers to surgery.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested applied behavioral analysis (ABA) therapy at the frequency of 120 hours per month, including 12 hours per month of supervision for treatment of the enrollees medical condition. Findings:  Two physician reviewers found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. Based on the documentation submitted for review, the patient has a diagnosis of autism. Researchers demonstrated that ABA therapy is medically necessary for children diagnosed with autism spectrum disorder (ASD). Researchers also showed that those with optimal outcome with a previous diagnosis of ASD had earlier and more intense ABA therapy. The literature  included primarily 30 to 40 hours per week of ABA. At this time there is no evidence that this patient is ready for a decrease in services. He is progressing with his current level and needs to continue at 120 hours per month of ABA with 12 hours per month of supervision. All told, the requested services are medically necessary for treatment of the patients medical condition.  Final Result: Two reviewers 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: One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. Two reviewers are board certified in child neurology 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 patient is a 62-year-old woman with allergic bronchopulmonary aspergillosis (ABPA). The patient has been treated with steroids and Sporanox. When Sporanox was discontinued the patients condition became worse. The patient wishes to continue treatment with Sporanox. The Health Plan indicates that Sporanox is not medically indicated for treatment of the patients ABPA.Review of the submitted information demonstrates that Sporanox is medically necessary for this patient. ABPA is an allergic manifestation of a bronchopulmonary aspergillosis infection. The typical treatment of ABPA is steroids, and at times, antifungal medications are added. However, in the case of this patient, the patients discontinuation of Sporanox led to a documented deterioration in her condition. Sporanox is an antifungal agent that has been approved by the Food and Drug Administration for the treatment of aspergillus pulmonary infection. Therefore, the patients use of Sporanox is medically appropriate and indicated.Based upon the information set forth above, I have determined that 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 13-year-old male enrollee has requested Vyvanse 100 mg for the treatment of the enrollees attention deficit hyperactivity disorder (ADHD). Findings:  The physician reviewer found that the submitted documentation indicates the patients symptoms have improved since receiving the higher dosage of Vyvanse (100 mg), there are great concerns regarding the potential side effects of using a dose of Vyvanse in excess of the FDA approved dosage for this medication.  Upon review of the literature, both in children and adults, the maximum dose studied was 10 mg/day. In animal studies, higher doses caused abnormal behavior or death. In human studies, a long list of side effects exists, including self mutilation and risk of suicide. Patients receiving the proposed dose need to be on a research protocol with close supervision to denote side effects and prevent the ultimate adverse side effects. Until this study is performed, this patient should not exceed the maximum dose approved by the FDA.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old male enrollee requested authorization and coverage for a referral to non-contracted provider. The Health Plan has denied this request indicating that the requested referral is not medically necessary for treatment of the enrollees ankle fusion follow-up care.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested referral is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for a Convaid Cruiser pediatric wheelchair with accessories. The ANSI/RESNA WC19 (WC19) standard specifies design and performance requirements for wheelchairs to be suitable for use in the safe transportation of children. Unlike a non-custom commercial stroller, the Convaid Cruiser pediatric wheelchair fulfills WC19 standards, enabling the patient to be safely transported on a school bus. Researchers stressed the importance of a five-point, wheelchair-integrated crash-tested harness, and wheelchair tiedown and occupant restraint system (WTORS) for the safest transportation of children with disabilities who use wheelchairs. Researchers concluded that individually designed wheelchairs should be maintained for children with cerebral palsy. Given the current medical literature and the patients diagnosis in this case, the requested equipment is medically indicated. The requested equipment will ameliorate the patients lack of safe dependent mobility. Without a custom wheelchair, the patient is at risk of developing abnormal posture due to poor truncal tone. He is also at risk of injury should his caretakers fall while carrying him. Therefore, a Convaid Cruiser pediatric wheelchair with accessories is medically necessary to prevent disease, disability, and other health conditions or their progression and to correct or ameliorate any physical or behavioral conditions.Final Result: The reviewer determined that the requested equipment 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 neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy and occupational therapy for treatment of the enrollees global developmental delay.  Findings:  The physician reviewer found that Schaaf and Miller report the effectiveness of sensory integration therapy by occupational therapists for children with multiple combinations of developmental sensory and motor delays. A controlled study demonstrated the effectiveness of sensory motor therapy in a childhood population (Miller, et al).  Although the study by Robert, et al. is a single case study, there was a dramatic improvement in behavior and attention when the child received occupational therapy utilizing sensory motor techniques.Children with speech delays can be readily and successfully treated (Law, et al). Goorhuis-Brouwer and Kniff specifically dealt with speech-delayed children, such as this cognitively normal patient, and pointed out that such normal children are candidates for successful speech therapy.  Two-year olds, who tested below the 10th percentile, as did this patient, most often required and subsequently benefitted from speech therapy (Emanuel, et al; Buschman, et al).   The medical community standard is to offer both occupational and speech therapy to children with this degree of speech and developmental delay.  Given this patients medical records and the available peer-reviewed medical literature, it is indicated that this patient will continue to benefit from both occupational and speech therapies. It is therefore, medically necessary that this patient receive both speech and occupational therapy. The recommendation is to continue his present combined program of both individual and group speech and occupational therapy for the next 12 months, with reassessment at six and twelve months.