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

A 20-year-old female enrollee has requested continued physical therapy (64 visits) for the treatment of her high-grade sarcoma in the right brachial plexus. Findings:  The physician reviewer found that the records provided for review demonstrate the patient has shown slow but consistent progress with PT thus far. Although the patients increase in range of motion is only reported to be a few degrees and she has had only incremental improvement in overall motor strength, considering the extent of her injury, she is likely to continue to improve slowly over an extended period of time. According to Centers for Medicare and Medicaid Services (CMS) guidelines, which are consistent with the standard of care in this setting, PT services are medically necessary when they are reasonable for treatment of the patients condition, progress is expected, and the services are sought to improve function. This patient, whose range of motion is still quite limited, is likely to benefit from additional PT services once per week for at least two months to prevent regression and continue progress for her adhesive capsulitis. Since this patient has not plateaued in her progress and has not reached maintenance level, skilled PT should continue until the patient has received two consecutive months of therapy without improvement in any active range of motion (AROM), strength, or functional activity (at which time she will have plateaued). The majority of providers recommend several months of therapy for treatment of adhesive capsulitis and this patient should be provided services until she has achieved maintenance level such that she no longer requires the services of a skilled physical therapist.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for home infusions of Gamunex-C and atovaquone. The current guidelines and medical literature do not recommended treatment of low pneumococcal antibody titers with immunoglobulin replacement therapy without the demonstration of poor response to vaccination with pneumovax. Many patients have low pneumococcal antibody titers and mount a normal response with normalized titers once vaccination is received with pneumovax. In addition, the medical records do not document a history of recurrent sinopulmonary infections, which would need to be demonstrated to meet the criteria for specific antibody deficiency and an indication for treatment with Gamunex-C and atovaquone. For these reasons, the requested home infusions of Gamunex-C and atovaquone are not medically necessary for this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer board certified in internal medicine with subspecialty certification in allergy and  immunology 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 46-year-old male enrollee requested authorization and coverage of a Dynatronics STS device. The Health Plan denied the request indicating that the requested equipment is considered investigational for treatment of the enrollees foot and leg pain.Three physician reviewers performed an experimental/investigational Independent Medical Review. 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. 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: The patient has requested authorization and coverage/reimbursement for a Saxenda pen injector. Findings: A study describes liraglutide as a glucagon-like peptide 1 (GLP-1) receptor agonist that has emerged as an effective therapy for type 2 diabetes and obesity. The authors further note that as an adjunct to a reduced-calorie diet and increased physical activity, treatment with liraglutide 3.0 mg may provide statistically significant and clinically meaningful weight loss. Another study notes that obesity treatment guidelines recommend the use of pharmacologic therapy in adults who have a BMI of 30 or higher. Given this patients history of obesity and as obesity may lead to the development of comorbidities such as diabetes and hypertension, the requested medication is medically indicated. Therefore, Saxenda pen injector is medically necessary for the 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 endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 48-year-old female enrollee has requested Botox injections for treatment of her headaches. Findings:  Three physician reviewers found that the use of Botox for chronic migraine following failure of standard preventive therapy is becoming widely utilized among headache specialists. A phase II study and two phase III studies have been completed, and the data is positive for reduction in headache episodes. These double-blind, randomized, placebo-controlled studies included over 3,000 patients and provide sufficient evidence of the effectiveness of Botox as a preventive therapy. Given the presence of chronic migraines in this case and the failure of multiple standard therapies, Botox injections are likely to be a superior treatment option for this patient.
Appeal type: Medical Necessity
Decision: Upheld

This 51-year-old male with multiple medical problems requests growth hormone (GH) for presumed adult GH deficiency (AGHD) based on non-specific symptoms, a low IGF-1 on several occasions and the response to an arginine/GHRH stimulation test. The patient is obese with diabetes, hypertension, sleep apnea, and dyslipidemia. At the time of his initial evaluation for possible hypogonadism he complained of some slight decrease in energy and decreased libido with some degree of erectile dysfunction.The evaluation by his endocrinologist revealed a normal to low normal testosterone, free testosterone, and bioavailable testosterone concentrations. The rest of the pituitary function tests and an MRI of the pituitary were also normal. An IGF-1 concentration was low. This lead to an arginine/GHRH stimulation test, which was abnormal. There is no evidence of AGHD in this patient. The diagnosis is usually made based on the clinical context, which is suggestive of some disorder of the hypothalamic-pituitary axis. Other causes for the patients symptoms could be his obesity, hypertension, sleep apnea or the medications he is taking. These must be considered before undertaking a course of testing for AGHD. Furthermore, all tested pituitary hormones appear normal in this patient and his MRI shows no structural lesion in the pituitary.The diagnosis of AGHD is based on the clinical context, signs and symptoms, as well as the results of biochemical testing. The patients signs and symptoms are sufficiently non-specific, and GH stimulation tests sufficiently inaccurate, that it is possible to have a false positive diagnosis. As such, there is insufficient evidence growth hormone therapy is medically indicated for this patient. 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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Vyvanse 70 mg three times daily (quantity of 90 per month). Vyvanse is a central nervous system stimulant that was first approved in 2007 for the treatment of ADHD. This patient has been diagnosed with ADHD. The patient has an established clinical relationship with his provider and meets with him at appropriate intervals. The current dose of Vyvanse was achieved after a systematic titration and has been in place for nearly two years. There is no evidence of side effect or misuse. The provider has posited a reasonable explanation for the supra-therapeutic dosing in this case. Indeed, individual variances in the cytochrome p450 system accounts for the rather unpredictable array of drug metabolism that is encountered in clinical practice, and patients that are rapid metabolizers require higher doses of medication to achieve the desired clinical effect. The current medication dose appears to be both efficacious and well-tolerated, with no evidence that it is unsafe. Moreover, the current regimen is optimizing the patients functionality and minimizing his illness burden. It is the recommendation of the treating provider to continue the medication at the current dose. Considering these factors, the relevant peer-reviewed literature, and current standards of medical practice, the requested Vyvanse 70 mg three times daily (quantity of 90 per month) is supported as medically necessary for treatment of this patients ADHD. Final Result: The reviewer determined that the requested medication dosage 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 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

The mother of a one-year-old male enrollee has requested dynamic orthotic cranial (DOC) banding for the treatment of the enrollees head shape. Findings:  The physician reviewer found that malformation of the head can influence the development of the jaw, temporal bone and eye orbit bones.  In addition, it has been associated with neurodevelopmental, visual, and auditory delays.  This patient has a short, wide head shape, brachycephaly, for which repositioning was unsuccessful.  DOC banding is a reconstructive measure in this instance with proven efficacy.  Because of the patients condition and the failure of repositioning, DOC banding was medically indicated and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for titers testing. The requested testing for TDaP antibody titers is not supported as medically necessary for evaluation of this patients medical condition. Obtaining TDaP antibody titers prior to administration of TDaP vaccine booster is not considered to be the standard of care or routine clinical practice. The Centers for Disease Control and Prevention (CDC) and American Academy of Pediatrics (AAP) policy on immunizations in adolescence routinely recommends TdaP as a single dose for those 11 through 18 years of age with preferred administration at 11 through 12 years of age. There is no indication from CDC or AAP for obtaining vaccine titers prior to administration of routine booster TDaP vaccine. TDaP boosters are necessary every 10 years, taking into account that the estimated duration of immunity against pertussis is no more than 10 years and there is a need to maintain high protective vaccine-induced antibody titers to prevent illness from pertussis infection. Furthermore, protective antibody titers to pertussis would not preclude vaccine booster administration. All told, the requested titers testing is not medically necessary for evaluation and treatment of this patients medical condition.Final Result: The reviewer determined that the requested testing is not medically necessary for evaluation 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 allergy and immunology 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested residential treatment center (RTC) services for treatment of his medical condition.   Findings: The physician reviewer found that although addiction specialty services and psychiatric care remained indicated, the clinical documentation does not demonstrate the medical necessity of treatment in a 24-hour supervised setting. The patient embraced recovery principles and expressed motivation for treatment. The patient was sleeping well and had no safety concerns or evidence of an acute psychiatric syndrome. Additionally, there was no evidence to suggest that a less restrictive treatment setting would have been insufficient. All told, the RTC rehabilitation services were not medically necessary for treatment of the patients behavioral health condition.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 physician 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: Upheld

A 61-year-old female enrollee has requested for Provigil for treatment of her excessive daytime sleepiness. Findings:  The physician reviewer found that Provigil is FDA approved for obstructive sleep apnea/hypopnea syndrome, excessive sleepiness due to narcolepsy and shift work sleep disorder.  The patient does not have, according to the documentation furnished, any of the above.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for referrals to an endocrinologist two times per year. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. Hypothyroidism is a common condition of thyroid hormone deficiency. While the presentation may vary greatly, common symptoms include fatigue, lethargy, cold intolerance, weight gain, constipation, change in voice, and dry skin. Levothyroxine is the treatment of choice for people with hypothyroidism. The diagnosis and treatment of hypothyroidism is generally carried out in a primary care setting. In this case, the patients hypothyroidism is straightforward, and she does not appear to have comorbid conditions, aside from her anxiety. The records indicate that it is reasonable for her to continue under the care of her primary care provider at this time. Therefore, the requested referrals to an endocrinologist two times per year are not medically necessary for this patient. Final Result: The reviewer determined that the requested services 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for the balloon sinus ostial dilation for treatment of the enrollees nasal obstruction and chronic sinusitis. Findings:  The physician reviewer found that at present, functional endoscopic sinus surgical techniques for the management of recurrent acute and chronic rhinosinusitis which are refractory to medical management are still considered the surgical treatment of choice. This patient reportedly had symptoms of recurrent acute rhinosinusitis with multiple episodes that was partially controlled with medications, but the symptoms recurred. The physical examination and CT imaging confirmed evidence of nasal septal deviation and mucous membrane thickening within the maxillary sinus with presence of a sinus cyst. However, the patient had no evidence of frontal sinus disease based on the history and on the imaging studies. The provider recommended standard endoscopic image-guided sinus surgery and nasal septal reconstruction, but did not mention the clinical addition of balloon sinus ostial dilation of the frontal and maxillary sinuses. Surgical endoscopic sinus surgery addresses the ethmoid and maxillary sinuses such that the clinical addition of a balloon is not indicated to manage the patients symptoms. Thus, the requested balloon sinus ostial dilation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two of the reviewers determined that the requested procedure is 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 otolaryngology 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 otolaryngology 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 otolaryngology 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 residential treatment center level of care for substance abuse for treatment of his behavioral health conditions.  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  In this case, the patient had concerning psychiatric symptoms and severe addictive illness.  Further, he failed to achieve sobriety after a truncated residential stay during the episode of illness.  He was drinking and had a history of alcohol withdrawal seizures.  Prior to admission, he was unemployed, psychiatrically distressed and did not have a support network conducive to recovery.  Based on these factors, residential placement was reasonably expected to improve the patients condition.  The structure and supervision of the residential facility afforded opportunity for a benzodiazepine taper, serial psychiatric evaluation, exploration of developmental traumas, introduction to chemical dependency counseling and after-care planning.  The residential level of care was safe, appropriate and consistent with good medical practice.  All told, residential treatment center level of care for substance was medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne gene test. Findings: Two of the three physician reviewers found that FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target which could guide the clinician in determining which chemotherapeutic agent would be useful. At this time, there is a lack of convincing evidence that the assay adds to the decision-making ability or yields a result that is reliably clinically beneficial. There are varieties of non-randomized studies exploring the value of molecular profiling, none of which have been convincing as to the efficacy of these analyses. A randomized trial by researchers did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the oncologists clinical judgment. Additionally, finding a mutation does not guarantee that a treatment directed at it will produce a clinically meaningful response. Therefore, FoundationOne gene test was not likely to have been more efficacious than other methods of evaluating this patient. Final Result: The reviewers determined that 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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.