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

The enrollee is requesting authorization and coverage for Humira CF pen, 40mg/0.4ml subcutaneous every other week. The enrollee has arthropathic psoriasis. The enrollee complains of pain in the sacroiliac joints and left index finger. She also reports burning in her right finger and now has a subcutaneous nodule over the proximal tendon on the palm. The enrollee has tried Vimovo, but it resulted in gastrointestinal upset. She has also tried and failed meloxicam. The provider reports the enrollee is refraining from methotrexate because the enrollees current use of Valtrex could raise concerns for kidney damage. Non-biologic disease-modifying anti-rheumatic drugs, such as methotrexate and sulfasalazine, are used primarily for peripheral psoriatic arthritis. In this enrollee, seronegative spondyloarthropathy is the bigger problem, for which tumor necrosis factor inhibitors are the preferred treatment. A professional society reports Sulfasalazine or methotrexate should be considered only in those with prominent peripheral arthritis or when tumor necrosis factor inhibitors are not available. The guidelines indicate non-steroidal anti-inflammatory drugs and tumor necrosis factor inhibitors remain the primary classes of medications for the treatment of spondyloarthritis. Literature shows tumor necrosis factor inhibitor therapy can be used when individuals have failed non-steroidal anti-inflammatory drugs, as is the case for this patient.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a two year-old female with primary ciliary dyskinesia and Kartageners syndrome are requesting authorization of two Synagis treatments (100mg) for respiratory syncytial virus (RSV) prophylaxis.Reviewers Findings:The reviewing physician found that primary ciliary dyskinesia, particularly as part of Kartageners syndrome, is a rare disorder that disrupts mucociliary clearance resulting in chronic sinusitis, chronic bronchitis, chronic cough and ultimately, bronchiectasis.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patient presented to a pediatric endocrinologist at 13 years, 3 months of age with a height of 135.2 cm, which is greater than 2.5 standard deviations below the mean for the patients age and gender. His height velocity is listed as 4.1 cm per year, which is below the 10th percentile for age and gender. His height is also greater than two standard deviations below his target height predicted by the heights of the patients parents. A request has been made for growth hormone therapy.Although growth hormone provocative tests were greater than 10mg/ml the patients baseline IGF1 was below the reference range for his age and gender (165 vs. 202-953). The patients growth response increased after growth hormone treatment. Although the patients growth was likely aided by the onset of puberty, when combined with the above data the patients presentation is consistent with a diagnosis of functional growth hormone deficiency and as such treatment with growth hormone is medically indicated and necessary. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intradialytic parenteral nutrition (IDPN) therapy. Findings:  The physician reviewer found that the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of published data demonstrating meaningful clinical outcomes are improved with IDPN therapy. A two-year multicenter, prospective, randomized study  demonstrated that IDPN provided to malnourished patients on dialysis did not improve patient outcomes. A study performed a prospective controlled study involving 113 dialysis patients receiving IDPN. The study demonstrated an improvement in albumin but no significant improvement in subjective local nutritional assessment. In addition, four subjects in the study developed uncontrolled hyperglycemia. A multicenter randomized controlled trial of 107 patients on hemodialysis demonstrated a statistically significant improvement in pre-albumin levels with intradialytic parenteral nutrition. However, the study was only 16 weeks in duration and did not assess mortality. In this case, the records do not show that the patient has contraindication to use of intradural nutritional supplements such as protein shakes provided by oral intake or via a gastrostomy or jejunostomy tube. In sum, IDPN therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested service 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 reviewers 1, 2 & 3 are  board certified in internal medicine with sub-specialty certification in nephrology and  are actively practicing. The reviewers are an 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for general anesthesia for magnetic imaging resonance (MRI) of the brain and auditory canal.A review by researchers found that vertigo and claustrophobia were two of the most common symptoms associated with MRI studies. The reviewers also state, The majority of patients should be able to do this without the need for anaesthetic care, but certain population groups are more predisposed to requiring assistance. Medical literature state, Anaesthetic input may be required for those with movement disorders, learning difficulties, claustrophobia or a reduced conscious level, when positioning is limited by pain, and for patients from intensive care unit (ICU). In most cases, general anaesthesia will be required; in some cases, sedation may be used, but consideration must be given to the length of scan and noise level that may make sedation difficult. The American Society of Anesthesiologists guidelines indicate, Observational studies report a high rate of successful imaging in patients receiving deep sedation or light anesthesia, with low rates of motion artifacts. The authors state, Observational studies and case reports also indicate that respiratory depression, oxygen desaturation, bronchospasm, drowsiness, agitation, and vomiting may occur with moderate sedation or light anesthesia. In this case, the patient has been diagnosed with vertigo symptoms and the provider recommended a brain and auditory canal open MRI. The patient reported claustrophobia and ineffectiveness of oral sedation with Valium. The medical literature supports the use of general anesthesia for patients requiring MRI with claustrophobia. Therefore, general anesthesia for MRI of the brain and auditory canal is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 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

A 32-year-old female enrollee requested authorization and coverage of  partial hospitalization program for the treatment of bulimia.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for day treatment at the Centre for Neuro Skills, five hours per day, three days per week, for a duration of three months. In this case, the patient has a documented history of traumatic brain injury (TBI) with speech, cognitive, and physical disabilities. The records document that the patients diagnoses include post-traumatic headache, exertion intolerance, and insomnia. The provider charted that the patients symptoms include blurred vision, balance and coordination issues, blood pressure and heart rate disturbances, and problems with attention and word finding. The patients provider has recommended day treatment due to the patients continued cognitive difficulties. Based on the current peer-reviewed medical literature, rehabilitation is indicated for patients with varying degrees of TBI. Increasing severity of TBI is usually accompanied by greater severity and complexity of impairments of body structure and function, which contribute to activity limitations and participation restrictions. Marklund and colleagues noted that the extended time frames for the recovery process for patients with the most severe TBI may continue over months or even years. Turner-Stokes and colleagues reviewed the evidence for multidisciplinary rehabilitation for acquired brain injury (ABI) in adults. The authors concluded that, Patients discharged from inpatient rehabilitation benefit from access to outpatient or community-based services appropriate to their needs. Given this support, the requested day treatment at the Centre for Neuro Skills, five hours per day, three days per week, for a duration of three months is medically necessary for 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 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

The patient is a 61-year-old woman with knee arthritis. She had a series of Synvisc injections last year, which provided pain relief for six months. A request has been made for a repeat series of injections. The Health Plan has denied this request on the basis that Synvisc is not medically necessary for treatment of the patients condition.The patient is relatively young to have severe arthritis and appears to be in eventual need of knee replacement. A second series of injections is a reasonable treatment option. The first series resulted in significant relief. A repeat series of Synvisc injections is appropriate to alleviate pain and postpone surgical intervention. Therefore, I have determined the requested injections are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

This case concerns a 12-year-old female patient with cerebral palsy and its complications (scoliosis and contractures). Her parents are seeking reimbursement and prospective authorization for physical therapy three times a week. The Health Plan has denied coverage for the therapy at issue and believes a step-down in therapy is appropriate.Vigorous intensive physical therapy and a program of exercises supervised by physical therapists and performed by members of the patients family, usually help patients with cerebral palsy avoid multiple, time-consuming and invasive corrective surgical procedures. The patient is followed by a pediatrician, developmental pediatrician, and pediatric orthopedist; all three physicians as well as the patients treating therapist have recommended continued physical therapy at a frequency of three times a week. Upon review of all of the submitted clinical information, physical therapy three times a week is medically necessary and essential for this patient and is likely to improve the patients quality of life and help prevent major complications. The patient should be re-evaluated every six months. If there is documented evidence of clinical benefit, therapy at this frequency should be continued.For the reasons set forth above, I have determined the therapy at issue was/is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 25-year-old female enrollee has requested eating disorder partial hospitalization program services provided for treatment of her eating disorder, not otherwise specified.  Findings:  The physician reviewer found that  this patient presented with chronic underlying issues of significance including insecurity, self-defeating behaviors, characterological issues, mood symptoms and anxiety, along with a distorted self-image and unhealthy food cravings. Such a confluence of symptoms necessitates on-going comprehensive specialty care.  However, based on the patients progress and stability despite her chronicity, continued partial hospitalization services were no longer medically necessary by the date indicated. In sum, partial hospitalization services were medically necessary from the time frame specified but not thereafter.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the medical model of rehabilitation at Valley Recovery Center (VRC) of Sacramento services provided for treatment of the enrollees alcohol dependence. Findings: The physician reviewer found that this patient reported withdrawal symptoms, however they were not rated via Clinical Institute of Withdrawal Assessment (CIWA) scales. In addition, he was not a danger to himself or others, and he was not aggressive or violent. The records describe the patient to be medically stable, although there is no medical admission physical. He was psychiatrically stable as his depression and anxiety did not require the confines of a residential setting and could have been safely and adequately managed on an outpatient basis. He attended group therapy, but the records do not document that the patient received individual psychotherapy or psychiatrist visits. He verbalized motivation and worked on steps. However, there was no mention of 12 step meetings or the attempt to obtain a sponsor. Based on the information provided, the patient did not require residential treatment, and the treatment at River City authorized by the Health Plan, would have been more than adequate to address the patients issues. Therefore, the medical model of rehabilitation services provided at VRC of Sacramento were not medically necessary for treatment of this patients medical 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 reviewer is board certified in psychiatry with sub-specialty certification in addiction 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 63-year-old female enrollee has requested the Flexitouch System for treatment of her bilateral lower extremity lymphedema.  Findings:  The physician reviewer found that evidence in the peer-reviewed medical literature is lacking to support the use of lymphedema devices with truncal appliances. As reported by Wilburn in a small, limited pilot study comparing the clinical effectiveness of the Flexitouch device compared to conventional therapy. Overall, the author concluded that further investigation is warranted given this short-term evaluation of the device. In addition Ridner and colleagues concluded that, Patients using the Flexitouch system were satisfied with the device and perceived it to be beneficial in management of their lymphedema. Despite these findings, the outcome is questionable as there was no control group from which to draw comparisons. One study by Adams and colleagues found future clinical trials are warranted as the current published medical literature has not conclusively demonstrated the efficacy of the lymphedema compression pump devices with additional truncal garments, or the marginal efficacy of these devices over conventional compression devices without the additional truncal garments. With regard to this patient, the Flexitouch device was requested because she was not reportedly improving with conservative therapy. The provider also states that the requested device has a truncal appliance to treat truncal edema, and produces light pressures, which are more tolerable for users. The patients medical records, however, have consistently reported good results with conservative therapy as all documented physician examinations in the records documented no edema on examination. Therefore, the requested device is not 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 Norco for treatment of his medical condition. Findings: The physician reviewer found that not all non-opioid treatment options have been utilized. Behavior therapy has not been done despite much research to support its use (Lee, et al). In addition, optimization of all non-opioid medications has not been documented (Mendlik and Uritsky). Chronic pain that has no hope for a cure can be considered palliative in nature and treatment. The step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting (Raffa and Pergolizzi). Since non-opioid options for pain relief have not been exhausted, the requested Norco is not medically necessary for treatment of this patients medical condition.  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.  Qualifications/Credentials: The physician reviewer is 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

A 22-year-old female has requested laser hair removal for treatment of her polycystic ovarian syndrome.   Findings:  The physician reviewer found that the medical records indicate that the patient has been diagnosed with polycystic ovarian syndrome and hirsutism.  She is currently being treated with Aldactone, which is a potassium-sparing diuretic that has anti-androgen properties.  This medication can help excessive hair growth.  In this patients case, it has not been established that the excessive hair constitutes an abnormal structure of the body.  The submitted documentation does not indicate the distribution of hair that the patient wishes to remove.  Additionally, there is no evidence of any associated functional deficit produced by the excessive hair growth.  All told, the requested laser hair removal is not reconstructive in nature and is not medically necessary in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned

A 43-year-old male enrollee has requested Acticon artificial bowel sphincter for treatment of his spina bifida and fecal incontinence.  Findings:  Three physician reviewers found that the requested artificial anal sphincter is an FDA approved device. The evaluation by a second provider determined that current less invasive means were not suitable for this patient due to his history of an anorectal pull through procedure as a child. The patients inadequate perineal muscles would preclude this as he essentially has a perineal colostomy. Wong and colleagues noted that indications for the procedure were patients with congenital anomalies, perineal colostomies, and patients who had failed conservative measures. Despite complications, patients reported successful placement with higher quality of life scores and incontinence scores. All told, the requested Articon artificial sphincter is likely to be more beneficial for this patients severe incontinence than any available alternative.
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.  Findings:  Two physician reviewers found that the current medical evidence supports the requested medication in this clinical setting.  Per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, the medical evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The requested medication is likely to prevent further development of fibrosis and prevent potential complications of advanced liver disease.  Therefore, Harvoni for eight weeks is medically indicated for the treatment of this patient. 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. 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.