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

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for Adaptive Rifton Tricycle (E1399). Young patients with autism present with a variety of behavioral and functional issues that can be problematic in their home, school, and community environments. These issues can include delays or inability to meet expected milestones in different domains of development, including sensory motor skills. As a result, multidisciplinary team involvement is essential to maximize the quality of life and well-being for the patient and the patients family. Acquisition of effective motor and sensory skills is required to perform many everyday abilities, such as language and communication, academic learning, social interaction, and self-care. Functional impairments can limit a patients ability to participate in age-appropriate and meaningful activities of childhood. Occupational therapy is the discipline that teaches patients to effectively interact with their environment and engage in desired daily activities. In this patients case, occupational therapy is appropriate to maximize sensory and motor functional independence, and participation in the school, home, and community settings. The potential benefits of occupational therapy in this patient population include improved toleration of sensory input, self-care, and upper extremity motor coordination, as well as stimulation of vocalization and language. Sensory integration therapy used by occupational therapy contributes to an improvement in motor, sensory, cognitive, emotional, communication, and social development in patients with autism. Currently, high-quality evidence is available to support the use of sensory-based therapies in patients with autism. However, there is a lack of quality research to support use of an adaptive tricycle as part of a sensory-based therapy program or a home exercise regimen that involves strategies for sensory retraining. Therefore, the requested Adaptive Rifton Tricycle (E1399) is not medically necessary to: 1) prevent disease, disability, and other health conditions or their progression; 2) prolong life; 3) promote physical and mental health and efficiency; or 4) correct or ameliorate any physical or behavioral conditions.Final Result: The reviewer determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 8-year-old male enrollee has requested a cardiology consultation featuring ECG/EKG monitoring while the enrollee is on ADHD medication for evaluation and treatment of the enrollees medical condition.  Findings:  The physician reviewer found that this case involves a patient with no known heart disease or arrhythmia, being treated with Concerta and Intuniv. He has not had any reported cardiac symptoms. His parents are requesting cardiac evaluation and ECG/EKGs while the patient is on these medications. A review of the current literature regarding the use and monitoring of children taking stimulant medications reveals no peer reviewed studies which support this practice. Studies have shown a lack of cardiac side effects associated with these medications and no evidence of any important ECG/EKG changes. It is generally recommended that monitoring of pulse rate and blood pressure be performed periodically with stimulant use. The 2008 recommendation published by the American Heart Association (AHA) for the use of an ECG/EKG prior to starting stimulant therapy is not supported by peer reviewed scientific data. Further, the AHA did not recommend ECG/EKGs for patients while on stimulant medication in the absence of symptoms, arrhythmias or structural heart disease; only blood pressure and heart rate measurements were recommended.All told, cardiology consultation featuring ECG/EKG monitoring is not medically warranted for this patient in the absence of any cardiac symptoms.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested authorization and coverage for Xeljanz XR for the treatment of psoriatic arthritis. The Health Plan denied this request as not medically necessary on the basis that he has not tried two of the preferred (formulary) drugs to treat his condition. They assert that studies do not show that Xeljanz XR works better than other drugs to treat the enrollees condition.Findings: The physician reviewer found that a review of the medical record indicates the enrollee was diagnosed with psoriatic arthritis that has involved his scalp, fingers, ankles, and other joints.  He has tried other medication with no change in his condition. He has been taking Xeljanz XR for several months and reports it is very effective for his condition and has no side effects.  A review of the medical literature indicates Xeljanz is now approved for adults with active psoriatic arthritis (PsA) who have had an inadequate response or intolerance to methotrexate or other disease-modifying antirheumatic drugs (DMARDs). In a trial involving patients with active psoriatic arthritis who had had an inadequate response to TNF inhibitors, Xelanjz (tofacitinib) was more effective than placebo over three months in reducing disease activity. Psoriatic arthritis (PsA) is a chronic inflammatory arthropathy. Therapy with anti-tumor necrosis factor (TNF) agents represents the first therapeutic choice for moderate and severe forms; however, PsA patients can experience anti-TNF failure, lack of efficacy, or adverse events. Evidence exists on the effectiveness of switching among different TNF inhibitors and most of the studies report that the main reason for switching to a second anti-TNF agent is represented by lack of efficacy (primary or secondary) and, more rarely, adverse events. This enrollee has documentation of treatment failure of two TNF inhibitors, whether these are the specific preferred TNF inhibitors or not, treatment with a third TNF inhibitor, such as Humira, has very low likelihood of benefit. Therefore, a biologic with a different mechanism of action, such as Xeljanz, is medically necessary.   Final Result: The reviewer determined that the service at issue is medically necessary for treatment of the enrollees condition. Therefore, the health plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male has requested a Flector 1.3% patch for treatment of his lateral epicondylitis.  Findings:  The physician reviewer found that based on the records provided for review, the requested Flector 1.3% patch is not medically necessary for treatment of the patients medical condition. The patient has a history of gastrointestinal (GI) irritation with oral non-steroidal anti-inflammatory drugs (NSAIDs). In the medical literature, oral NSAIDs are contraindicated in patients who have a side effect of GI irritation due to increased risk of gastric ulcers and gastric perforation. However, the requested Flector 1.3% patch is not medically necessary because it is not more or equally effective than other appropriate alternative oral medications that may serve as treatment of the patients pain due to epicondylitis. Taylor and Hannafin presented a systematic review on the evaluation and management of elbow tendinopathy. The authors concluded that non-steroidal anti-inflammatory drugs and corticosteroid injections yield moderate symptomatic relief in short-term but do not demonstrate benefit in long-term follow-up. Lin and colleagues performed a meta-analysis of randomized controlled trials comparing topical NSAIDs with placebo. The authors found that topical NSAIDs were superior to placebo in relieving pain due to osteoarthritis only in the first two weeks of treatment. The study concluded that the randomized controlled trials of short duration only (less than four weeks) have assessed the efficacy of topical NSAIDs in osteoarthritis. After two weeks, there was no evidence of efficacy superior to placebo. No trial data support the long-term use of topical NSAIDs in osteoarthritis. It is appropriate to avoid oral NSAIDs in patients with history of GI irritation as to prevent development of gastric ulcers and in-turn gastric perforation. However, the Flector 1.3% patch is not medically necessary because treatment efficacy for chronic pain and inflammation due to arthritis has not been proven in the medical literature. Tylenol and intermittent short acting opioids are considered safe to use in patients with a history of gastric irritation. These medications are also similarly efficacious as topical NSAIDs in treating inflammatory pain. All told, the requested Flector patch is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Vosevi for 24 weeks. McPhee noted that patients with genotype 3 HCV are associated with an increased risk of accelerated liver disease progression. However, the current guidelines for treatment of HCV recommend 12 weeks of therapy. 12 weeks of therapy with sofosbuvir, velpatasvir and voxilaprevir provided high rates of sustained virologic response among patients across HCV genotypes in whom treatment with DAA [direct-acting antiviral agent] regimen had previously failed. Based on the available data, treatment with Vosevi is supported for 12 weeks, not 24 weeks. There is a lack of documentation to demonstrate that a longer course of therapy is needed for this patient. A 12-week course of Vosevi with ribavirin is appropriate therapy for this patient. Therefore, Vosevi for 12 weeks is medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in infectious 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: Urgent Care
Decision: Upheld

A 59-year-old male enrollee has requested for transurethral resection of the prostate performed at a non-plan hospital indicating the services at issue were required on an urgent basis. Findings:  The physician reviewer found that this patient may have ultimately required a TURP procedure to alleviate his obstructive uropathy, this procedure was not urgent in nature. The patient was initially provided with a Foley catheter, which relieved his symptoms. As long as the Foley catheter was in place, the patients symptoms would not have required immediate intervention and thus he could have returned to his network provider. Given that a Foley catheter was in place and should have provided the patient with relief from his symptoms of urinary obstruction, a prudent layperson would not have thought further intervention was required prior to returning to his service area.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old male enrollee has requested residential treatment center services for treatment of the enrollees Aspergers disorder and schizoaffective disorder.  Findings:  The physician reviewer found that the patient has a significant family psychiatric history of bipolar disorder in his paternal grandmother and schizophrenia in a paternal uncle. Overall, he presented with multiple risk factors for self harm, including his age and gender, a history of self mutilation, affective, psychotic, and anxiety symptoms, a history of impulsivity, and abuse of substances. The patient persisted in having psychotic symptoms until very close to the time of discharge, and even at that time, had some near-psychotic delusional thought processes. His medications were actively being titrated and changed throughout the majority of the admission. The psychiatrist who treated this patient throughout his residential treatment stay documented that the patient required inpatient services for the entire period at issue. The provider stated that in order to progress to a point where he could be safely discharged, the patient required the 24-hour supervision and direction of a residential treatment level of care. Given the patients command auditory hallucinations to harm others, suicidal intent and self mutilating behavior, he clearly required inpatient psychiatric services during the period under review. He presented with a complex complement of symptoms and possible diagnoses. At the time of admission, his diagnoses were not entirely clear. With a framework of a working diagnosis and treatment regimen, the psychiatric services at issue were appropriate to prevent relapse and services at a lower level of care would have likely been inadequate. For these reasons, the entire length of stay was medically necessary to advance the patient to a level of stability where he was reasonably safe to be discharged.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old male enrollee has requested corrective eye surgery for treatment of his cataracts.  Findings:  The physician reviewer found that based on the medical records provided for review, the patient had a preoperative refractive error of -2.75 to -4.00 in right eye and -1.25 in the left eye. He elected to receive a monofocal intraocular lens, calibrated for near. Following surgery, his visual acuity improved to 20/25 at distance corrected for a refractive error of -3.00, and J1 (uncorrected) near. After his surgery, the patient decided that he would rather have a multifocal lens, to allow him better distance vision along with his near vision. However, this second surgical procedure to remove his present intraocular lens and replace it with a multifocal intraocular lens is not without substantial risk. The risks are higher for this patient, given his history of obesity, diabetes, and a prior myocardial infarction. This patient has achieved a very good result, with a refractive error almost identical to his preoperative refractive error. Thus, replacing this patients present intraocular lens with a multifocal intraocular lens is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a magnetic resonance imaging (MRI) of the thoracic spine (CPT 72146). In this case, the patient has tried multiple types of pain management, however the documentation does not reflect information about current treatment. While the patient has attempted conservative treatment in the past, given the recurrent nature of back pain, the same type of conservative management, including non-steroidal medications and physical therapy, are indicated for each recurrence. The American College of Radiology (ACR) appropriateness criteria for chronic neck and low back pain note that MRI is usually not appropriate in the absence of red flags raising suspicion for an underlying condition. The in case, the patient presents with pain but without symptoms that would raise red flags such as radiculopathy, prior tumor, recent trauma, or infection. Given that intensive conservative management is recommended first for every episode of pain, the requested service is not currently medically indicated. Therefore, magnetic resonance imaging (MRI) of the thoracic spine (CPT 72146) is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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 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

A 60-year-old female enrollee has requested for MRI studies of the cervical spine and brain and MRA studies of the neck and brain for evaluation of her symptoms of visual and auditory disturbances and cognitive and mobility impairments. Findings:  The physician reviewer found that MRI of the brain and MRA of the brain and cervical arteries are standard of care in a patient with transient ischemic attack (TIA) symptoms, especially given the prolonged and atypical nature of the symptoms. The MRI of the brain and MRA of the neck and brain were medically appropriate and necessary. The MRI of the cervical spine was not medically necessary and was not appropriate because the patients symptoms did not suggest radicular or myelopathic processes.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested  speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that this young patient has an identified delay in expressive speech that is estimated to be greater than 50%. In addition, he has a greater than 33% delay in receptive language abilities. In the clinical studies, speech therapy is indicated with any delay greater than 25% (Carey, et al). Further, an extensive review of the literature including meta-analysis by Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Similarly, Feldman and colleagues concluded that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. With intervention, approximately half of children delayed at 2-years catch up to peers by 3-years of age. Those children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders while those who participate in speech-language treatment show better improvement than those without therapy. This patient has a history of prematurity and transient communication hydrocephalus which are both associated with language and speech delay. Given the reliable scientific data in support of the effectiveness and utility of speech therapy, its use in the management of this patients speech delay is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-year-old male enrollee has requested prescription medication Strattera for treatment of attention deficit hyperactivity disorder (ADHD).  Findings:  The physician reviewer found that The American Academy of Child and Adolescent Psychiatry (AACAP) notes that although stimulants are generally endorsed as first-line treatment for ADHD and are  purported to have a greater treatment effect than atomoxetine (Strattera), there are additional considerations in this instance. The AACAP also indicates that atomoxetine may be an appropriate first-line medication in persons with an active substance abuse problem, anxiety or tics. The AACAP also recognizes that each patients treatment must be individualized and that family and clinician preferences should be recognized. Given the family history, treatment of the patients ADHD with Strattera is medically indicated and  consistent with the AACAP practice guidelines.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested home nurse aide services for treatment of her bilateral wrist fractures status post open reduction with internal fixation.  Findings:  The physician reviewer found that services are considered medically necessary when they are used to treat or prevent an illness or injury, are generally accepted as standard of care, and are not considered investigational. In general, medically necessary rehabilitation services require that the provider be a skilled licensed nurse or therapist. In the case under review, the patient required the assistance of a certified home health aide to perform her ADLs, but did not require the services of a skilled therapist or nurse. The services were intended to provide assistance with self-care tasks rather than manage impairment. Therefore, the home nurse aide services were not medically necessary during the said timeframe for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the brand name medication, Exforge 5 mg/160 mg two tablets per day. Medical records provided indicate the patient has been taking Exforge since 2/11/08. Based on the limited medical records provided, there is no indication that the patient has had an allergic reaction or is intolerant to the generic form. Generic forms of this medication are rated by the Food and Drug Administration (FDA) to be equivalent and equally effective to the brand name. The requested dose for the medication is more than the highest dose approved by the FDA. This patient has a history of hypertension and has been taking the medication Exforge since 2008. He is taking a daily dose which includes 10 mg of amlodipine and 320 mg of valsartan, which is the maximum dose recommended for this medication. The documentation and medical records provided for review did not provide any information concerning other drugs that the patient may have tried which might have been effective. In conclusion, due to the lack of medical records and documentation provided and literature review recommendations, the denial of coverage for the brand name medication, Exforge 5 mg/160 mg, two tablets per day was not found medically necessary for this patient. The generic version of the medication can be used to treat this enrollees medical condition. Final Result: The reviewer determined that the requested medication/treatment is not medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in internal medicine and 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 similar medical condition.
Appeal type: Urgent Care
Decision: Overturned

A 29-year-old female enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that the ED records state that the patients pain was localized in the abdomen and described as an aching, pressure-type of pain with no aggravating or alleviating factors. Given the possibility of obstruction, the literature would suggest erring on the side of caution and encourage patients with similar symptoms to be evaluated in the ED without delay.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old male enrollee requested authorization and coverage of the medication Provigil. The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollees sleep apnea.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.