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

Nature of Statutory Criteria/Case Summary: The patient with a history of short stature. The patients height is less than 2 standard deviations (SDs) below the normal range for age and gender, and she is noted to have poor growth velocity. A prescription drug form reported the patient is consistently below the first percentile at -2.27 SDs below the mean. The provider has recommended treatment with growth hormone therapy. At issue in this case is whether Nutropin AQ NuSpin is medically necessary for treatment of this patient.The submitted documentation supports the medical necessity of the requested medication. Idiopathic short stature (ISS) is defined by a height below -2 SDs below the mean without findings of disease or pathology that can explain short stature. Growth hormone is approved by the U.S. Food and Drug Administration (FDA) for children with ISS whose current height is below -2.25 SDs below the mean, in whom the predicted adult height is unlikely to fall within the normal range, and the epiphyses are not closed. This patient has poor growth velocity of 3.82 cm per year, and her predicted adult final height of 152.4 cm based on her skeletal age is much shorter than her target mid parental height of 170.3 cm and lower than normal female in society of 154 cm. Her birth history, past medical history, and family history rule out constitutional delay of growth, puberty, and familial short stature. Her laboratory studies have been normal, which rule out other causes of short stature, including chronic medical conditions, hormone deficiencies, genetic conditions, medication use, and poor nutrition. Her insulin like growth factor (IGF-1) was also normal, indicating she does not have growth hormone deficiency. Given these findings, the requested Nutropin AQ NuSpin is medically necessary for this patient.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 pediatrics with expertise 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male has requested five hours of speech therapy per week and five hours of occupational therapy per week for treatment of his autism.  Findings:  The physician reviewer found that the in-Plan speech therapist and the non-Plan speech therapist had good concordance in reporting a severe expressive speech delay and essential non-functional language skills. The medical communitys standard of practice for autistic children is to provide both occupational and speech therapy to autistic children.  The medical literature supports both occupational therapy and speech therapy in this population.Pfeiffer, et al. reported on an extensive meta-analysis of the literature and concluded that occupational therapy is effective in reducing many of the problematic mannerisms associated with autism. May-Benson and Koomar also performed a meta-analysis of 27 journal articles involving occupational therapy utilizing sensory integration techniques for autistic children. Their conclusion based on the meta-analysis was that sensory integration was effective, but studies were inconclusive regarding the duration or the amount of occupational therapy necessary for positive effects.  According to Myers, et al. people with autistic spectrum disorders (ASDs) have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite sills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services. Further, Turner, et al. reports on a controlled study comparing autistic children who did and did not receive speech therapy. Those that did receive therapy had far greater communication skills than children who did not receive speech therapy (Turner, et al.). The report of the Speech and Language Association states that all autistic children can benefit from speech therapy.  This report emphasizes that age, either early or late in life, is not a barrier to speech therapy.In sum, it is medically necessary for this patient to receive individual speech therapy for one hour per week and individual occupational therapy for two hours per week as recommended. The parents request for additional hours is not consistent with the therapists recommendations and is not supported by the record. Both modalities should reassess the patient at 6 and 12 month intervals.  If the patient is making progress, the therapies should continue.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee requested inpatient hospitalization for medical treatment of the enrollees hypercalcemia, hyperkalemia, and falls.  Findings:  The physician reviewer found that based on the available medical records, inpatient hospitalization services were not medically necessary. The records indicate the patient had stable vital signs and her electrolyte disturbances had resolved. There were no complaints related to unresolved symptoms and the patient was able to walk. Endurance training does not require a continued hospital stay. Moreover, she did not need continued daily physician visits or consultations and had no daily nursing needs. All told, her care needs could have been provided at an outpatient level. Therefore, inpatient hospitalization services were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old female enrollee has requested Enbrel 25mg, twice weekly for the treatment of her polymyalgia rheumatica. Findings:  The physician reviewer found that several studies support the use of tumor necrosis factor inhibitors in the treatment of both polymyalgia rheumatica and giant cell arteritis, a frequently associated condition. Catanoso and colleagues published an open label study of six patients with polymyalgia rheumatica who were able to reduce their prednisone dose significantly while on Enbrel. Similarly, the tumor necrosis factor inhibitor infliximab was shown in a pilot study and in case reports to reduce acute-phase reactants such as IL-6 and to reduce patient steroid requirements. High levels of IL-6 are thought to be associated with continued active disease and with prolonged high doses of steroids. In this case, the treating rheumatologist has documented both failure of steroids and oral steroid-sparing agents to control the patients disease, and clinical and laboratory response to Enbrel. Enbrel 25mg, twice weekly, is medically appropriate and indicated for treatment of this patients refractory polymyalgia rheumatica.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage Dexilant (dexlansoprazole) 60 mg delayed-release capsules. Findings:  The physician reviewer found that gastroesophageal reflux disease (GERD) and esophagitis are at least partially caused by mechanical defects in esophageal motility. Scarpignato and colleagues indicate that since proton pump inhibitors (PPIs) do not correct the underlying pathophysiological motor abnormalities responsible for reflux, ongoing treatment at a sufficient dose is likely to be needed to maintain remission. Usai and colleagues state that insufficient acid suppression can result in complications of GERD, such as persistent erosive esophagitis, esophageal stricture, esophageal ring, and Barrett's esophagus. Comparison of proton pump inhibitors, including rabeprazole, omeprazole, lansoprazole, and pantoprazole, has found no significant difference in control and healing of gastroesophageal reflux disease. Dexilant, unlike all other proton pump inhibitors, is released in an extended fashion. This delivery system results in an extended plasma concentration and a higher mean 24-hour intragastric pH than other proton pump inhibitors. In a study by Fass and colleagues, a significant majority of patients (88%) requiring other PPIs twice daily were able to control symptoms on Dexilant once daily. Dexilant is also more effective to treat heartburn than alternatives such as esomeprazole. American College of Gastroenterology guidelines for the treatment of GERD do recommend proton pump inhibitor therapy, especially in patients with complications such as esophagitis. In this case, the patient did not have sufficient control with multiple proton pump inhibitors, pantoprazole and omeprazole. Although additional similar proton pump inhibitors have not been attempted, they are unlikely to be effective after failure of omeprazole and pantoprazole. Dexilant, unlike alternatives, has been effective in this case. Therefore, Dexilant (dexlansoprazole) 60 mg delayed-release capsules are medically necessary for the treatment of the patients medical condition.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 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: Overturned

A 46-year-old female enrollee requested (belimumab) Benlysta for medical treatment of her systemic lupus.   Findings:  Two physician reviewers found that Benlysta is an antibody inhibitor of the B-lymphocyte stimulator that has been demonstrated to be safe and effective in at least two randomized clinical trials where it was compared with placebo in the treatment of systemic lupus erythematosus (Thanou-Stavraki and Sawalha). In addition, Benlysta is U.S. Food and Drug Administration (FDA) approved for systemic lupus erythematosus (Furst, et al). This patient has been tried on multiple standard agents and now her provider has recommended Benlysta. Further, the patient meets the detailed criteria by which systemic lupus erythematosus is diagnosed (Petri, et al). All told, Benlysta is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 43-year-old with an eight-month history of Dupuytrens contracture in his left hand. The patient believes Kenalog injections are the most appropriate therapy for treatment of his condition. The patient has been evaluated by a number of providers who have not recommended Kenalog injections. The Health Plan has denied authorization for the requested therapy.The Health Plans denial should be upheld. There is no scientific evidence demonstrating Kenalog injections are beneficial for treatment of the patients condition. Kenalog injections are not considered standard of care for treatment of Dupuytrens contracture. Furthermore, there are standard available treatments that are known to be effective for treatment of the patients condition. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

`Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency neurolysis on both sides at facets L3 to S1 for treatment of the enrollees low back pain. The submitted documentation does not establish the superior efficacy of the requested services. Repeated radiofrequency ablation for lumbar facet syndrome may provide pain relief.  The medical evidence indicates that radiofrequency ablation may be successful in treating lumbar spine pain in a repeated fashion in selected patients. In this patients case, he has received radiofrequency ablation in the past. Based on the documentation, his most recent radiofrequency ablation was performed several years ago. This treatment was performed at L4-S1. Radiofrequency ablation can be repeated with success. However, when the previous radiofrequency ablation was greater than one year prior, confirmation injections are needed. In this case, the records do not document that confirmation testing was performed. Therefore, radiofrequency neurolysis on both sides at facets L3 to S1 is not likely to be more efficacious than other available treatment modalities. Final Result: Two of the three reviewers determined that the requested services are 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 reviewer number one is board certified in anesthesiology with sub-specialty certification in pain medicine 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.Physician reviewer number two is board certified in anesthesiology with sub-specialty certification in pain medicine 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.Physician reviewer number three is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 48-year-old female who is seeking revision of multiple abdominal scars. She has been seen by her primary care physician, gynecologist, and plastic surgeon. The patient indicates her scars are disfiguring and her cholecystectomy scar itches a great deal with intervals of pain and numbness. She has requested authorization for scar revision of all of her abdominal scars. The Health Plan has determined the requested surgery is not medically necessary.The submitted photographs of the patients scars have been reviewed as well as medical records from her primary care physician, gynecologist, and plastic surgeon. The submitted evidence demonstrates the patient is an obese female with several large but normal scars on the abdomen. There is no conclusive evidence the scars are causing pain or functional problems. Therefore, I have determined that the requested surgery is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 29-year-old female enrollee requested authorization and coverage of hyperbaric oxygen therapy. The Health Plan  denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees toxic encephalopathy. Three physician reviewers performed an experimental/investigational Independent Medical Review. All three of the physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Humira 40 mg/0.8 mL, four times a month. Findings:  The physician reviewer found that  Current medical literature supports the continuation of Humira 40 mg weekly. In the ULTRA 1 trial, which was a high-quality randomized double-blind placebo-controlled trial, weekly use of Humira allowed an increase in maintenance of remission . In the ULTRA 2 trial, it was part of the protocol to change patients to weekly Humira if response was not adequate on Humira every two weeks . The trial advanced nonresponders at week eight to weekly therapy as well as week eight responders. Both groups contained a fraction that responded to dosing frequency increase. In the ULTRA 3 trial, weekly dosing of Humira was used for inadequate response or for flare . In a subset analysis of ULTRA 2 patients, those on weekly therapy had week-52 response rate of 25% after failing therapy given every 2 weeks . Changing to alternative therapy may result in loss of remission, disease flare, disease complications, and hospitalization.  For these reasons, continuation of Humira 40 mg/0.8 mL, four times a month is supported as medically necessary for treatment of this patient.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 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: Overturned

The parent of a 17-year-old female enrollee has requested intensive outpatient program (IOP) eating disorder services for treatment of the enrollees eating disorder.  Findings:  The physician reviewer found that the American Psychiatric Association (APA) criteria for outpatient treatment versus IOP are nearly identical. The APA suggest that weight for outpatient treatment is generally greater than 85% IBW and for IOP the guidelines recommended greater than 80%. For motivation, the APA indicates fair-to-good for outpatient services and fair for IOP. Since the criteria are so similar, the choice between outpatient and IOP must be a mutual one between the patient, family, and provider. In this case, the treatment notes indicate that therapy in-Plan has not been successful and the patient has started to regress. Specifically, she has started to restrict and purge and she is not following her meal plan. Therefore, the requested IOP services with the independent therapeutic team are medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a seven-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 20 hours per week of applied behavioral analysis (ABA) therapy and three hours per week of oversight/supervision for treatment of the autism spectrum disorder. Findings:  The physician reviewer found that The requested 20 hours per week of ABA therapy and three hours per week of oversight/supervision provided from  were not and are not medically necessary for this patient. According to the documentation submitted for review, the patient has been documented as making progress with ABA therapy, and the records do not demonstrate a medical indication for 20 hours per week of ABA therapy and three hours per week of oversight/supervision. The Health Plans authorization of 15 hours per week of direct ABA services and two hours per week of oversight/supervision is medically reasonable and appropriate in this clinical setting. Final Result: The reviewer determined that the services at issue were not and are 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 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: Upheld

A 63-year-old male enrollee has requested occupational therapy and physical therapy for treatment of his status post right middle cerebral artery stroke.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient has had a severe stroke, with residual deficits six months post event.  He is status post craniotomy and cranioplasty.  The medical literature shows that recovery from severe stroke is facilitated by formal physical therapy, and that neuroplastic changes associated with functional improvements can continue for months to years.  However, the current medical evidence indicates that most of the motor recovery occurs within three months after stroke onset.  Balaban and colleagues performed a retrospective study to evaluate functional outcome in patients with middle cerebral artery stroke.  The authors noted that patients do not always experience increased functional improvement with increased duration of inpatient therapy.  In this patients case, while the clinical records indicate improvements post stroke, the therapy notes do not document significant functional improvements post cranioplasty.  All told, continued occupational therapy and physical therapy from the date specified and forward were not and are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee has requested inpatient skilled nursing care, physical therapy, and occupational therapy for treatment of his multiple medical conditions. Findings:  The physician reviewer found that the submitted documentation demonstrates that by the date in question, the patient had reached a functional plateau. Therefore, he does not require daily skilled physical or occupational therapy to maintain or improve his functional status. Improvement in rehabilitation rests largely on neurological and/or muscle recovery following injury. The patients ongoing medical issues are preventing neurological recovery and he has therefore reached his maximal recovery potential in terms of daily skilled rehabilitation therapy. Furthermore, the patient no longer presented with daily skilled nursing needs. While the patient has ongoing medical issues, his conditions can be managed at a non-skilled custodial level of care with appropriate specialty follow-up, as proposed by the Health Plan. Thus, the denial was appropriate and should be upheld.