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

The parent of a 5-year-old female enrollee has requested 25 hours per week of Discrete Trials Training for treatment of the enrollees autism. Findings:  The physician reviewer found that adequate therapy, according to Myers and colleagues consists of intensive intervention, with active engagement for at least 25 hours per week, in systematically planned, developmentally appropriate educational activities designed to address identified objectives. The authors cite three studies that clearly showed superiority of intensive ABA therapy over eclectic approaches, as that offered with Easter Seals. The Easter Seals Initial Assessment and Recommendation Guidelines were reviewed and it is noted that they are based on the Early Start Denver Model, which is ideal for toddlers under 2 12 years of age. The cited article from Dawson and colleagues on the early Start Denver Model specifically targets toddlers less than 2 12 years old. This study also established the superiority of comprehensive developmental behavioral interventions for toddlers. It is clear that there are major differences between the treatment plans offered by Easter Seals and the requested provider. The Easter Seals plan of treatment is not an equivalent treatment program for treatment of this patient. The patient has been receiving therapy at her current provider with reports of considerable progress. In this particular case, transitioning the patient to the Easter Seals program may actually hinder or even cause regression of the patients progress at her current provider. As such, I find that 25 hours per week in the current provider's plan of treatment is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center level of care services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient did not have a comorbid psychiatric illness, protracted withdrawal syndrome or medical condition that would have necessitated the delivery of care in a residential treatment setting.  He was physically healthy and not taking medication.  He was motivated in his quest for sobriety.  At the start of the timeframe in dispute, the patient had completed 30 days of residentially-based treatment, the duration of which is consistent with community practice standards.  He had planned to attend an intensive outpatient program.  Further, the patient had no prior history of community programming, outpatient drug and alcohol counseling, anti-craving medication, intensive outpatient services, partial hospitalization or placement in a sober living environment. This is significant since modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment. Moreover, there was no documentation to suggest that comprehensive, evidence-based services provided a less restrictive setting would have been inadequate after an uncomplicated detoxification and 30-day course of residential treatment. Thus, residential treatment center level of care services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Avastin for treatment of his medical condition.  Findings:  Three physician reviewers found that the current medical evidence does not support the services at issue in this clinical setting.  Avastin is not U.S. Food and Drug Administration (FDA) approved for thymoma and is not found to have a non-FDA approved indication in major drug compendia.  The medical literature does not support Avastin for the treatment of this patient.  All told, the superior efficacy of Avastin has not been established. Final Result:  Three reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for high-intensity focused ultrasound (HIFU).Findings:  Three physician reviewers found HIFU has been increasingly used for the treatment of localized prostate cancer within the last decade. It has the theoretical potential of decreasing gastrointestinal, genitourinary and sexual toxicity. Potential candidates are patients with low to moderate risk prostate cancer. The available literature mainly consists of prospective case series and retrospective studies showing short term to intermediate term outcomes for localized prostate cancer. There is a lack of controlled trials available for analysis, and there is a lack of long-term survival data. American Urological Association/American Society of Radiation Oncology/Society of Urologic Oncology guidelines note clinicians should inform low-risk prostate cancer patients who are considering focal therapy or HIFU that these interventions are not standard care options because comparative outcome evidence is lacking. Therefore, HIFU was not likely to have been superior over other treatment options. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in urology and are 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: Overturned

The parent of a five-year-old male enrollee has requested additional speech therapy for the treatment of the enrollees delayed speech. Findings:  The physician reviewer found that this patient initially presented with expressive and receptive language delay and verbal apraxia. Verbal apraxia, or apraxia of speech, is an impairment in planning and coordinating movements for speech production.  While unstructured spontaneous speech or recitation may be possible in some cases, the ability to voluntarily initiate goal-directed speech or imitate speech is impaired. This is a deficit in motor programming and sensorimotor processing at the central level. This type of impairment is frequently seen after stroke or with congenital disorders that affect the brain, but may also be seen in otherwise normally developing children. It is a neurological disorder that requires intensive treatment. While this patient has significantly improved with prior therapeutic interventions, such that verbal apraxia is no longer considered to be a concern, he continues to have difficulties with expressive and receptive language and articulation skills. Speech therapy is therefore medically indicated and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old female enrollee has requested post-operative use of an elastomeric infusion pain pump for treatment of the enrollees medical condition status post right shoulder arthroscopy.  Findings:  The physician reviewer found that on review of the medical records provided for review, the elastomeric infusion pain pump used for this patients post-operative pain was medically necessary for pain control following extensive right shoulder surgery. As noted by the patients provider, the medical literature supports elastomeric infusion pain pumps as a safe and effective device for post-operative pain management in patients undergoing extensive surgery. Ilfeld and colleagues performed a randomized, double-blinded, placebo-controlled study to evaluate the efficacy of patient-controlled regional anesthesia via a portable infusion pump for outpatients undergoing moderately painful orthopedic surgery of the shoulder. Following the study, the authors concluded that portable infusion pumps significantly decreased post-operative pain after orthopedic surgery of the shoulder. They also concluded that in addition to providing potent analgesia and increasing patient satisfaction, perineural infusion pumps decreased opioid requirements and their associated side effects. In addition, Capdevila and colleagues conducted a multicenter randomized controlled study to compare the efficacy of continuous perineural and patient-controlled ropivacaine infusion at home after orthopedic surgery with patient controlled intravenous morphine for functional recovery and post-operative analgesia. Following the study, the authors reported that perineural infusion using an elastomeric pump with patient-controlled analgesia bolus doses optimizes functional recovery and pain relief while decreasing the consumption of rescue analgesics and the number of adverse events. Similarly, Harvey and colleagues double blind, prospective, randomized study revealed that use of elastomeric infusion pumps provided effective post-operative pain control in patients following arthroscopic shoulder surgery. Thus, in this patients post-operative care, the use of the elastomeric infusion pump has been demonstrated to be medically necessary and should therefore be reimbursed.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Forteo 20 mcg/dose pen injection subcutaneously daily. Findings:  The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. The patient has been estrogen deficient for many years. She has a diagnosis of rheumatoid arthritis, a disease that causes bone loss. For treatment of this condition, her provider had treated her with prednisone, which promotes bone loss. The patient has osteoporosis as determined by the FRAX scores, calculated with information based on patients medical history. The FRAX score places patient at 27% risk for a major osteoporosis fracture and 9.1% risk of a hip fracture within 10 years. Based on this criteria the patient qualifies for pharmacological treatment. The National Osteoporosis Foundation (NOF) guidelines indicate that U.S. Food and Drug Administration (FDA) approved medical therapies should be considered with low bone mass (osteopenia) and a US-adapted World Health Organization Scientific Group (WHO) 10-year probability of a hip fracture greater or equal to 3% or 10-year probability of any major osteoporosis related fracture greater or equal to 20%. The choice of Forteo for treating this patients osteoporosis is well supported by the patients records. There is some medical evidence that have shown antiresorptive agents, such as bisphosphonates and denosumab, to decrease bone turnover. In theory, this mechanism could interfere with healing of bone. The medical literature has not been consistent on whether these agents are favorable or unfavorable for the healing of vertebral fusion surgeries. However, the medical literature is consistent in indicating beneficial effects of teriparatide (Forteo) in the healing of vertebral fractures and fusion surgery. The patient has an upcoming spinal fusion surgery. This patient has osteoporosis that must be treated with an FDA approved medication to prevent a major osteoporotic fracture. Therefore, Forteo 20 mcg/dose pen injection subcutaneously daily is medically necessary for the treatment of this patients osteoporosis. Final Result: The reviewer 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 endocrinology 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of her behavioral health condition. Findings:  The physician reviewer found that TMS is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder.  The American Psychiatric Association (APA) has endorsed TMS for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial. In this case, the patient presents with chronic affective illness. She has failed multiple adequate psychopharmaceutical trials. The documentation reveals that this patient has pursued, but not exhausted other standard therapies used to combat depression. However, considering the medical records, endorsement from the APA and the expanding peer-reviewed literature base, TMS represents a safe, appropriate treatment consistent with good medical practice. The therapy would be reasonably expected to improve the patients condition and prevent a more serious episode of illness. As such, the requested therapy is medically necessary for treatment of the patients behavioral health condition. 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 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 51-year-old female enrollee has requested physical therapy (PT) for her rehabilitation. Findings:  The physician reviewer found that the PT provided actually addressed several different therapy goals. Initially treatment focused on the patients right shoulder. She demonstrated progress, but could have continued with strengthening through a home exercise program. However, the patient was also given a prescription for physical therapy for her right ankle. There was limited documentation in this regard, and extension of treatment would have been sufficient. The patient received her leg braces and additional PT for gait training was indicated. She progressed at which time she walked 18 five times. Her walking distance declined after that date, probably due to an exacerbation of her chronic right shoulder problems. The progress note indicates the patient had scheduled surgery for rotator cuff repair. The patient had plateaued with ambulation and there was limited potential for additional gains due to the rotator cuff problems; PT should have been discontinued.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee has requested a conversion to a duodenal switch procedure for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient has shown considerable effort to lose and maintain weight loss on her own through diet and exercise programs to no avail. There may be a mechanical factor involved in the maladaptive eating behaviors known as the soft calorie syndrome, where only soft or liquid foods are tolerated and a metabolic failure exists resulting in a poor outcome. Additionally, some studies suggest that open RNYGBP is more prone to result in pouch dilatation. All told, conversion to duodenal switch is medically indicated in this case in view of the patients inability to maintain weight loss combined with her worsening comorbidities and dumping syndrome. The risks of non-operative treatment greatly outweigh revisional bariatric surgery especially with her rising BMI and her worsening comorbidities. As shown in a recent study by the British Medical Journal, women who are obese in their middle ages reduce their odds of living a long healthy life by 79 percent, compared to leaner women. The proposed procedure is a medically appropriate option for this patient and should be authorized.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old male enrollee requested authorization and coverage of a CPAP. The Health Plan denied the request indicating that the requested CPAP is not medically necessary for treatment of the enrollees sleep apnea.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested device is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for eight weeks for treatment of her hepatitis C virus (HCV).  Findings:  Two physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Therefore, Harvoni for eight weeks is medically necessary to prevent further progression of fibrosis due to ongoing HCV infection and prevent potential complications of advanced liver disease, long term. 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: The three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are 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: Experimental/Investigational
Decision: Overturned

A 39-year-old female enrollee has requested Botox injections for the treatment of her migraine headaches.  Findings:  Two physician reviewers found that this patient has a history of refractory migraines with chronic daily headache. There are no FDA approved treatments for chronic migraine. She has tried and failed preventive medications, as well as SSRIs and biofeedback, and requires ongoing treatment with abortives. Botox has considerable data consistent with a positive benefit as a migraine preventive, especially when the frequency of attacks is high (chronic migraine). Based upon the patients history and current condition, Botox should be authorized for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee has requested authorization and coverage for a panniculectomy for treatment of the enrollees excess skin. Findings:  The physician reviewer found that a review of the submitted medical documentation and photographs demonstrates the medical necessity of the requested panniculectomy. This patient has a significant history of weight loss. She presents with a severe overhanging abdominal pannus that is symptomatic. The photographs document that the pannus is below the pubis. Additionally, the patient has intertrigo and superficial rashes secondary to the overhanging pannus. A panniculectomy is consistent with the standard of care in this setting. As noted by Manahan, et al. The abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus. Panniculectomy can treat these symptoms  The documented clinical findings demonstrate the patient has a severe overhanging pannus and related symptoms resulting in a functional abnormality. As such, the requested panniculectomy is medically necessary to treat the patients functional impairment.
Appeal type: Experimental/Investigational
Decision: Overturned

A 56-year-old female enrollee has requested for speech therapy, cognitive rehabilitation, and sensory integration therapy for treatment of her mild traumatic brain injury/post concussive syndrome. Findings:  Two physician reviewers found that speech therapy for cognition and integration studies has been documented since 1985, if not earlier. A study by Kennedy, et al. showed improvement in cognition and organizational skills for work and daily functioning with appropriate therapy. Hence, the services at issue are well-accepted for patients with traumatic brain injuries. Such methods are implemented routinely in acute and sub-acute conditions with periodic short-term therapy. As this patient was experiencing decreased functional capacity due to increased demands, it was reasonable and appropriate to employ a short course of therapy to return her to her previous level of functioning.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old female enrollee has requested 60 intermittent uses of catheters per month for treatment of her C5-6 quadriplegia and spastic neurogenic bladder.  Findings:  The physician reviewer found that, considering the extensive nature of this patients neurologic injury, which impairs her upper body strength and coordination, the necessity of the additional catheters is clinically indicated. In general, the clean technique works well for many paraplegics with normal upper body coordination and strength. The justification for the clean method assumes a patient has the requisite capacity and ability to wash and clean the catheters, which is not an accurate description of this patients clinical scenario. Rather, this patients situation makes it impossible to achieve the clean method with proper cleaning with soap and water. In addition to her impairment, this patient continues to work, which complicates her circumstances even further as she is away from home in a public restroom. According to the records provided, the patient is catheterizing between four to six times per day despite her inability to adequately practice the clean method to prevent infection. Therefore, her request for 60 catheters per month is medically reasonable.