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

A 23-year-old female enrollee has requested twice weekly outpatient psychotherapy treatments (rather than the approved once per week treatment) for treatment of her major depressive disorder.  Findings:  The physician reviewer found that the submitted documentation demonstrates the patient has been participating in outpatient psychotherapy and has achieved an important therapeutic goal of abstinence which maximizes her chances for recovery and minimizes suicidal risk. While she appeared to have some continued instability of mood, medication titration could have been performed in the context of less frequent visits. The submitted information fails to establish the medical necessity for twice weekly psychotherapy. The patients condition does warrant ongoing monitoring and intervention to promote further recovery and/or prevent worsening. However, the patient can be safely and effectively treated with psychotherapy at a frequency of once per week. All told, the requested twice weekly outpatient psychotherapy treatments during this time was not and is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female has requested coverage for Welchol for treatment of her hypokalemia.  Findings:  The physician reviewer found that based on review of the available records, this patient presents with several coronary risk factors and has a history of a myocardial infarction in 2007. In this circumstance, aggressive treatment of dyslipidemia to achieve a goal LDL less than 70mg/dl is recommended. However, there is no indication in the medical records provided that the patient has allergy or intolerance to formulary statin medications including cholestyramine, which is the preferred generic alternative to Welchol. Also, there is inadequate evidence based data that demonstrates improved cardiac outcomes by adding non-statin cholesterol medications to patients already on statins as compared to patients receiving statins alone. For example, the recent AIM-HIGH trial conducted by Boden and colleagues, did not demonstrate incremental outcome benefit by adding niacin to patients already receiving statin medication. Consistent with these findings, the requested medication has not been demonstrated to be medically necessary in the treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 53-year-old female enrollee has requested for Botox injections for treatment of her migraine headaches.   Findings:  Two physician reviewers found that the study by Frietag and colleagues found that Botox was statistically superior to placebo for the primary endpoint of reduction in migraine headache episodes. The authors further indicate Botox showed numerical superiority to placebo for acute medication use and Migraine Disability Assessment Scores. Adverse events were rare. Although Botox is not a first-line therapy for migraine headaches, there is clear indication for its use in patients with chronic headache states that are resistant to standard therapies.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for accessories (HCPCS E1399 x 20) for an approved pediatric standing frame. The available documentation indicates that this patient presents with Pallister-Killian syndrome, which is a multi-system disorder that is characterized by hypotonia in infancy and early childhood. The patients provider has recommended use of a standing frame and related accessories. The current positioning methods for young patients with hypotonia and delayed motor development include use of weight bearing, standing, and mobility devices. Use of these devices depend on a patients ability to maintain a safe posture and functional alignment of the spine, pelvis, and extremities, as well as the risk of complications from their underlying medical condition. Current research has demonstrated that developmental benefits including social, language, and cognitive skill development, may be observed in young patients with motor disability who use standing and related accessories. In a cohort of children with motor delays the usual method of positioning needs to be the most efficient one for everyday tasks and environmental conditions (Paleg, et al.). In this patients case, the accessories are a crucial part of safe positioning and appropriate alignment of body parts, including trunk, pelvis, hips, knees and ankles. Given this support, the requested accessories (HCPCS E1399 x 20) for an approved pediatric standing frame are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested accessories 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 physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation 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: Experimental/Investigational
Decision: Upheld

A 60-year-old female enrollee has requested for use of a real time heart monitor for evaluation of her atrial fibrillation.  Findings:  Three physician reviewers found that guidelines from the American College of Cardiology (ACC) in 2006 regarding the recommended treatment of PAF. The decision to anticoagulate the patient with aspirin versus Coumadin is typically made by assessing her risk factors such as age, valvular disease or CAD. Real time telemetry has not been shown to change the assessment of the need for anticoagulation. Electrocardiogram monitoring has been recommended in the assessment episodes of asymptomatic PAF or to judge the adequacy of rate control. However, the guidelines do not, as of yet, recommend a real time component to the monitoring. Prolonged or frequent monitoring may be necessary to reveal episodes of asymptomatic atrial fibrillation (AF), which may be a cause of cryptogenic stroke. Ambulatory ECG (i.e., Holter) monitoring is also useful to judge the adequacy of rate control. This technology may provide valuable information to guide drug dosage for rate control or rhythm management.
Appeal type: Medical Necessity
Decision: Upheld

A 28-year-old female enrollee has requested partial hospitalization program (PHP) for treatment of her behavioral health condition. Findings:  The physician reviewer found that the partial hospitalization program (PHP) was not and is not medically necessary for this patients medical condition.  During the patients PHP treatment her medications were adjusted, she continued to display fair motivation to address restricting behaviors, address caloric intake and engaged in dialectical behavior therapy (DBT) to address distress tolerance as well as cognitive behavioral therapy (CBT) to reduce her fears regarding weight gain. The patients clinical notes indicate that the patients weight is at 87-90% of expected, displaying good motivation and participation in treatment recommendations with no further medication changes, no acute metabolic changes and no autonomic deregulations. The patients need for continued structure and inability to independently control restrictive behaviors and her co-occurring mood disorders could have been treated in a sub-acute level such as an intensive outpatient program (IOP) level of care. This would be consistent with the patients diagnosis and meets the clinical need for continued rehabilitation, specific goal acquisition, continued exploration of trauma and medication oversight. Therefore, the patients condition of anorexia nervosa could have been treated at an IOP level of care. All told, the services at were not and are not medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old female enrollee has requested two albuterol inhalers every 45 days for treatment of her asthma.  Findings:  The physician reviewer found that in this patients case, the submitted documentation does not demonstrate the medical necessity of the requested medication quantity.  The increased use of short-acting beta-agonist inhalers such as albuterol is a marker for poorly-controlled asthma. Albuterol should be used on an intermittent basis and is not intended for disease control.  The current medical evidence does not support the requested medication quantity for the treatment of this patient.  In this clinical setting, additional evaluation to exclude contributing factors resulting in poorly controlled asthma may be appropriate.  All told, two albuterol inhalers every 45 days are not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 54-year-old female who has a history of obesity, hypertension, hypothyroidism, osteoarthritis, and chronic lymphedema. The patient indicates physical therapy has provided her with pain relief. In February 2005, the patients physician recommended the patient receive additional physical therapy sessions for her lymphedema. The Health Plan has determined additional physical therapy sessions are not medically necessary. A consultation visit with a lymphedema clinic has been authorized for the patient. Evaluation through a lymphedema clinic is more clinically appropriate than additional physical therapy at this time. It is likely the consultation with the lymphedema clinic will result in a more effective treatment program specific to the patients needs. Therefore, I have determined that the requested therapy 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 54-year-old male has requested Taclonex Ointment for treatment of psoriasis.  Findings:  The physician reviewer found that Donovex Cream is ineffective for this patient. Dovonex ointment does work, but is no longer available, except in Taclonex Ointment. Clobetasol was used, but didnt work. Clobetasol is stronger than Diprolene. The manufacturer no longer makes the ointment form of Dovonex. There is no medical reason to insist on using the combination the Health Plan requires.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for acute inpatient hospitalization services. In this case, the patient underwent appropriate inpatient testing and empiric treatments. Although no frank seizures were witnessed, and no evidence was found on electroencephalogram (EEG), empiric outpatient treatment with antiepileptics for a few months if indicated may be a reasonable and common practice.  In this case, continued hospitalization for ongoing inpatient diagnostic treatment was not indicated. The records indicated that further testing, such as screening for an ovarian teratoma causing encephalitis, was decided against due to the resolution of the patients white blood cell count on spinal tap. An empiric trial of intravenous immunoglobulin (IVIG) was not indicated as autoimmune encephalitis was not strongly suspected. The patients clinical status had improved, and an encephalitis panel was negative by the date of discharge. Given that this patient required only custodial care, and as further diagnostics and follow-up could have been performed on an outpatient basis, the services at issue were not medically indicated. Therefore, acute inpatient hospitalization 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 neurology with sub-specialty certification in vascular neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old male enrollee has requested for Procrit injections for treatment of his metastatic neuroendocrine tumor. Findings:  The physician reviewer found that Procrit is used very restrictively in patients with cancer by their oncologists. Those with hemoglobin levels below 10 must not be getting potentially curative chemotherapy, and must have their iron stores evaluated to determine if they would be able to respond to the Procrit. The use of Procrit was a reasonable maneuver in an attempt to obviate this need, and it was successful. As such, in this clinical situation, the use of Procrit seems to be more appropriate than any other approach available.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old male enrollee has requested for dental services for treatment of his fractured teeth.   Findings:  The physician reviewer found that although the hospital report at the time of the accident makes no mention of the patients teeth, given his other injuries, tooth pain would have been an inconsequential finding at that time.  Nonetheless, it is highly likely that the post accident tooth fractures were the direct result of trauma experienced during the head injury suffered.  The extent of the patients injuries, including broken neck vertebrae, indicates that he had a blunt force trauma to the head and face.  It would not be unusual for teeth to be severely stressed at that time and incur incipient fracturing.  These incipient fractures would ultimately evidence themselves months later after the continued stress of daily life, as seen in this case by the multiple fractures of #4, 12, and 13, and the symptomatology of tooth #31.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for gene panel test (FoundationOne) for treatment of the enrollees prostate cancer. Findings:  The physician reviewer found that Although tumor based molecular assays are recommended by the National Comprehensive Cancer Network (NCCN) guidelines for men with clinically localized disease, generalized molecular testing such as FoundationOne is not supported by the NCCN guidelines for prostate cancer. The use of molecular profiling for prostate cancer and other solid tumors is the subject of ongoing clinical trials. The available literature indicates that the use of molecularly targeted agents, outside their indications, do not improve progression free survival compared with treatment recommended by a provider in heavily pretreated patients with cancer. There is also some data suggesting that intratumoral heterogeneity limits the use of gene expression analysis as a potential prognostic or predictive biomarker in patients treated with androgen deprivation therapy. As such, the use of FoundationOne testing is not likely to be more beneficial than any available standard therapy. Therefore, the gene panel test (FoundationOne) provided was not likely to have been more effective than the standard methods available for evaluating this patients medical condition. Final Result: All three reviewers determined the services at issue were 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:  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: Overturned

A 60-year-old female enrollee requested genetic testing for medical evaluation of possible Ehlers-Danlos Syndrome, type IV. Findings:  Two physician reviewers found that the testing was likely to be more effective for this patient than other available options. EDS type IV is associated with aneurysms and arterial dissections and for patients with the disorder there is a significant risk of carotid arterial dissection associated with angiography. Given the mothers genetic diagnosis of this dominantly inherited connective tissue disorder and the inherent risks of vascular manipulation in this disorder the testing at issue was indicated. Therefore, genetic testing was more likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Dupixent.Findings: Dupixent is an interleukin-4 receptor alpha antagonist that is FDA approved for the treatment of adult patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies. There are very few treatments approved for this condition, and this medication has quickly become a standard, preferred therapeutic option by dermatologists in the community. The medication was approved in 2017, and therefore has not yet made it into Guidelines (these were last updated in 2014). The data supporting its use in moderate-to-severe atopic dermatitis is substantial and it has a very favorable side effect profile in comparison to other systemic agents. In this case, the patient has a history of severe eczema that has not been adequately controlled by treatment with topical steroids, tacrolimus ointment, phototherapy, and courses of prednisone. Dupixent is indicated for the treatment of eczema under these circumstances and has a favorable side effect profile. Accordingly, the requested medication, Dupixent, is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology, with subspecialty certification in dermatopathology, 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: The patient has requested authorization and coverage for rituximab infusions. Zappa and colleagues reported on a case of a patient with antisynthetase syndrome with severe interstitial lung disease (ILD) and acute respiratory failure and found that with infusions of anti-CD20 therapy (rituximab) the patients clinical conditions improved rapidly. Dasa and colleagues performed a review of the literature documenting the treatment of 45 patients with ILD secondary to antisynthetase syndrome. The authors found that rituximab treatment was well tolerated in the majority of cases. Given that rituximab is the standard of care in treating patients with progressive ILD, the requested services are medically indicated. Therefore, rituximab infusions are medically necessary for the treatment of this patient.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 internal medicine with sub-specialty certification in pulmonary disease and critical care 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

A female enrollee requested authorization and coverage of an increase in her monthly Zomig prescription. The Health Plan has denied the request indicating that an increase in the enrollees monthly Zomig prescription is not medically necessary for treatment of the enrollees migraine headaches.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested increase in the enrollees monthly prescription of Zomig is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested a 12 week course of Sovaldi 400 mg tablets for medical treatment of his chronic hepatitis C virus genotype 2.   Findings:  Three physician reviewers found that guidelines from the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) for treating patients with hepatitis C virus support the safety and efficacy of Sovaldi in this clinical setting. Thus, the requested 12 week course of Sovaldi is medically necessary for treatment of this patients hepatitis C virus.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for urgent care services provided for treatment of an emergency medical condition. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the dates of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The services provided were not necessary for treatment of an emergency medical condition. There was no emergent medical condition noted in the records submitted for review. The patient had run out of a prescription medication for anxiety. He denied suicidal or homicidal ideation. He was not hallucinating. His insight and judgement were good. Although he was anxious, the urgent care evaluation did not meet the criteria for emergency medical services. Therefore, the services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services, the patient was experiencing continued foot pain following a twisting injury. Although his symptoms were not acute in onset, his pain was persistent, increasing, and accompanied by swelling and pain with weight bearing. He was found to have a foot fracture requiring immobilization and non-weight bearing. Therefore, the services provided were necessary for treatment of an emergency medical condition.  Final Result: The reviewers determined that the enrollee received emergency medical services on a portion of the dates of service at issue. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician reviewer number one is board certified in emergency 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.