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

A 45-year-old female enrollee requested authorization and coverage for aquatic therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees medical condition.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: Experimental/Investigational
Decision: Upheld

A 39-year-old male enrollee requested percutaneous tibial nerve stimulation (PTNS) for medical treatment of the enrollees overactive bladder syndrome.  Findings:  Two physician reviewers found that the available clinical data does not support the utility of PTNS as equivalent or superior to standard first- and second-line therapies. Moreover, there is a paucity of evidence demonstrating improved health outcomes at long-term follow-up. Although this patient has been treated with various modalities, the records do not establish that standard therapies have been exhausted. Given the lack of evidence supporting the safety and efficacy of PTNS in this clinical setting, the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old male enrollee has requested Vyvanse 30mg for the treatment of the enrollees attention deficit/hyperactivity disorder (ADHD), inattentive type. Findings:  The physician reviewer found that Vyvanse is FDA approved for the treatment of ADHD in children and adults. Vyvanse is a prodrug of dextroamphetamine and offers certain advantages, such as longer duration of symptom control, and fewer side effects in some patients. Both efficacy and safety have been observed in the literature. This patient has tried three different strengths of Concerta. According to the submitted medical documentation, this patient is responding well to the current dosage of Vyvanse. A change in medication could significantly exacerbate his illness. Vyvanse was and is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lantus SoloStar insulin pen. Intensive insulin therapy resulting in good glycemic control has been shown to prevent and reduce the progression of diabetes-related complications in patients with type 1 diabetes (Lind, et al.). Currently, intensive glycemic control is generally achieved through multiple daily insulin injections or continuous subcutaneous insulin infusions through an insulin pump. Insulin is available in vials as well as prefilled pens. Studies have shown that the insulin pen can be significantly easier to use and less painful than the conventional vial and syringe (Ramadan, et al.). Compared with the vial and syringe method, insulin pens are more accurate, associated with greater adherence, and preferred by patients because of their convenience and ease of use (Cuddihy, et al.). This patient has reportedly successfully managed his diabetes with insulin pens in the past and he states that the insulin pen method was substantially more effective than using a vial and syringe. The patients provider supports the return to use of an insulin pen for this patient. For these reasons, the requested Lantus SoloStar insulin pen is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication dosage form 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 subspecialty certification in endocrinology, diabetes, and metabolism 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 has requested coverage for past sub-acute substance abuse residential treatment provided for treatment of his alcohol dependence.   Findings:  The physician reviewer found that the patient has a history of alcohol dependence.   His pattern of drinking was causing family discord.  However, his spouse was listed in the record as supportive.  The patient denied any physical complaints or history of complicated withdrawal, seizures, or delirium tremens.  At the time of presentation, the patient had been sober for four days and was not taking any medication.  The submitted documentation fails to demonstrate the medical necessity of the services at issue.  The documentation provided did not include severity-of-illness and level-of-function multidimensional assessments that would justify residential services.  Per the American Psychiatric Association, residential treatment is indicated for patients who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack substance-free social supports or sufficient motivation to remain abstinent in an ambulatory setting.  In this patients case, he was motivated for care.  He had good family support.  Aside from irregular participation in Alcoholics Anonymous, he had not trialed any less restrictive interventions.  The current medical evidence does not support the services at issue in this clinical setting.  Considering these factors, intensive outpatient or partial hospitalization program level of care would have been medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for FoundationOne testing and associated CPT codes. Findings:  Two out of three physician reviewers found that FoundationOne is a molecular assay that explores the mutations of an individual patients cancer cells. The goal of the assay is to identify a specific mutation or target which could guide the provider as to which chemotherapeutic agent would be useful. However, there is a paucity of evidence that the FoundationOne assay adds to decision making ability, or yields a result that is reliably clinically beneficial. There are non-randomized studies exploring the value of molecular profiling, but the results have not been convincing as to the efficacy of such an approach to treatment. One randomized trial did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the providers clinical judgment. Currently, the data suggests that finding a mutation does not support treatment directed at that target to produce a clinically meaningful response. For these reasons, the requested FoundationOne testing and associated CPT codes are not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. One reviewer found that the requested FoundationOne testing and associated CPT codes are likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that 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:  One reviewer is board certified in oncology with subspecialty certification in hematology and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene expression profiling Decision Dx UM assay (CPT 84999) for evaluation of the enrollees uveal melanoma. Findings:  The physician reviewers found that the current medical evidence favors the use of this test in the post-operative surveillance of patients with ocular melanoma. All told, the gene expression profiling Decision Dx UM assay (CPT 84999) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications:  Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in medical oncology and 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: Upheld

A 56-year-old female enrollee has requested for skilled nursing care for treatment of her conditions. Findings:  The physician reviewer found that there are no inherent advantages or improved outcomes with inpatient versus outpatient settings of rehabilitation.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old male enrollee has requested the medication Relistor for treatment of his chronic pseudo-obstruction. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication in this patients case.  There is sufficient support for the use of Relistor in this clinical setting.  Relistor is indicated for patients with opioid-induced constipation who are receiving palliative care and fail to adequately respond to laxative therapy.  Per the submitted documentation, this patients constipation is of functional origin, largely opiate-induced, and he has not responded to conventional therapy.  The available records do not demonstrate that aggressive treatment for his cancer is planned, and limited treatment options are available.  All told, Relistor is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for applied behavioral analysis (ABA) therapy. Findings:  The physician reviewer found that based on the documentation submitted for review, the patient does not have a diagnosis of ASD. In 2010, 2013, and 2014, the patient did not meet criteria for ASD using the DSM-IV. In 2015, the diagnostic criteria changed to DSM-V. Based on DSM-V criteria many children with PDD, NOS diagnosis no longer meet the criteria for ASD. The documentation submitted for review describe difficulty with oppositional behavior, inattention and social difficulties. These symptoms are likely due to the patients learning disabilities that include her working memory and processing speed with particular difficulty in listening comprehension. She also has symptoms of ADHD. The patient has adaptive deficits, inattention, communication difficulties and slower learning. In sum, the patients symptoms are consistent with a learning disability with particular difficulty with listening comprehension. She needs visuals to help her remember what she is supposed to do next. She also has inattention, difficulty processing verbal input and remembering what she just heard. In sum, the records do not support a diagnosis of ASD and ABA therapy is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 Sovaldi and Daklinza for treatment of her hepatitis C.  Findings: The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions.  In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 12 weeks.  This patient is ineligible for alternative regimens requiring peginterferon due to a pre-existing condition.  For these reasons, Sovaldi and Daklinza are medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications 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 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 61-year-old female enrollee requested steroid injections (cortisone injections), one injection in each knee on the same day, for treatment of the enrollees bilateral knee degenerative joint disease.  Findings:  The physician reviewer found that documentation fails to demonstrate the medical necessity of the requested services.  Per the medical records, this patient had blood sugar levels in the 400s following bilateral knee cortisone injections.  It is appropriate to perform one steroid local injection at a time with monitoring of blood sugar levels following the injection.  The overall efficacy of intra-articular steroid injections in nonoperative management of osteoarthritis is supported as a standard of care, but the providers recommendation for avoiding bilateral injections with doubling of the steroid load is medically appropriate. There have been reports of hyperglycemic reactions following intra-articular steroid local injection.  All told, the requested steroid injections (cortisone injections), one injection in each knee on the same day are not medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld

A 46-year-old female enrollee has requested emergency services for the treatment of her condition. Findings:  The physician reviewer found that this patients Health Plan covers emergency services according to the prudent layperson definition. This states that an individual must be suffering from the sudden onset of symptoms of such severity (including severe pain) that a prudent layperson would believe the lack of immediate medical attention to result in serious jeopardy to her health. Although this patient did report pain, the pain started the day prior. She required only acetaminophen for pain control in the emergency department. The patient did not have the acute onset of any other symptoms of a severe ear problem such as dizziness, vomiting, or hearing loss. While her ear pain warranted medical evaluation, this care did not need to be provided on an emergent basis. Because this patient was not experiencing the sudden onset of acute symptoms, her symptoms do not meet criteria for an emergency.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 53-year-old female with a reported history of anorectal hygiene problems as a result of excess skin following substantial weight loss. The record does not include any physician documentation of medical complications related to her concerns. The patients primary complaint is related to the inconvenience of performing anorectal hygiene due to her excessive skin. She has requested authorization and coverage for a buttock lift, which has been denied by the Health Plan on the basis that it is not medically necessary.The patient complains of problems with post-bowel movement hygiene related to her excess buttock skin. Skin excess following massive weight loss is a common clinical condition. The submitted photographs do not demonstrate skin excess that is exceptional or different than what is ordinarily found in either obese or post-bariatric patients.  Furthermore, review of the medical literature does not reveal any studies or topic reviews identifying perirectal hygiene as an indication for surgery in this group of patients. The records do not document any skin rashes or perirectal inflammation secondary to her condition. Buttock lift is generally considered a cosmetic procedure, and the patients complaints are subjective and primarily related to inconvenience rather than a true medical problem.  The Health Plan is correct that the patients concerns should be manageable with normal hygiene and perhaps treatment directed toward hardening her stools. Improvement of anorectal hygiene is not a standard or medically necessary indication for a buttock lift.Based upon the information set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female enrollee has requested authorization and coverage for Lidoderm 5% patch (30 per month) for treatment of the enrollees cervicalgia, cervical degenerative disc disease, and myofascial pain syndrome.  Findings:  The physician reviewer found that the use of Lidoderm patches in myofascial pain syndrome is considered off-label use. However, the use of topical lidocaine and injectable lidocaine for trigger points and myofascial pain has been proven to be effective for isolated myofascial pain areas through both direct action and placebo effect. The patient in this case is on a very potent narcotic analgesic and addictive skeletal muscle relaxant, the addition of another sedative systemic analgesic or anti-neuropathic or myofascial pain agent is concerning for both dependence and adverse reactions. To avoid these risks, the use of topical lidocaine 5% (Lidoderm) patches poses little risk of dependence or systemic adverse reaction. This patient has reported relief with trigger point injections and the use of Lidoderm patches. In this case, its use is supported by randomized and placebo controlled clinical trials. Further, this is a well accepted and prescribed modality in chronic back and myofascial pain and it is reasonable to supplement the use of injections and potent narcotic analgesics to help control her chronic pain. Given this patients long standing history of pain and the use of schedule II narcotic analgesics, the supplemental use of Lidocaine patches is a medically necessary adjunct to help reduce her pain and narcotic use. The Lidoderm 5% patch should be approved as long as the patient continues to experience significant documented relief without adverse effects.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 56-year-old male with degenerative joint disease of the left knee. X-rays show severe degenerative joint changes in all three components. In February 2004, the patient underwent arthroscopy, debridement and partial medial meniscectomy. The patients physician has recommended the patient use the Bionicare System. The Health Plan has denied coverage for the requested equipment on the basis it is not medically necessary.There is no Class I published data establishing the Bionicare System as an effective treatment of degenerative joint disease. The efficacy of this treatment remains unproven. Conservative therapies are likely to be more beneficial for this patient than the requested equipment. Therefore, I have determined that the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

This patient is a 5 year 9 month old male with a diagnosis of autism. He has been receiving speech therapy twice per week since May 2002. He has been working on expressive language and pragmatic language during this time.  He is followed by a developmental pediatrician, a pediatric psychiatrist and a pediatric neurologist. All of these physicians have recommended the patient receive ongoing speech therapy twice per week.The patients parent has requested reimbursement for the speech therapy the patient received as of January 2006 as well as prospective authorization for continued speech therapy. The Health Plan has denied this request on the basis that speech therapy is not medically necessary for this patient.Upon review of the speech therapy reports it appears the therapy is primarily focused on expressive language delays, which are educational in nature. However, when evaluating the handwritten notes it is clear the context of the therapy is primarily directed toward pragmatic speech, which is more functionally based speech and affects the patients ability to function in the community and not just in the classroom. Given the documented evidence of improvement from the patients three physicians as well as the evidence of improvement in the speech therapy progress notes, the therapy at issue is medically warranted. The patient should continue to be followed by one of his physicians every six months. In addition, his speech therapist should provide an evaluation every six months documenting the patients progress using objective measures. Based upon the information set forth above, I have determined the therapy at issue was/is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.