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

An enrollee has requested authorization and coverage for a right leg prosthesis with a microprocessor. The submitted documentation does not reveal that the patient would be unable to perform his activities of daily living with an appropriately fitted non microprocessor standard knee prosthesis. Furthermore, there is no objective evaluation of the patient's back or spine from a physician or imaging study of the spine that provides objective evidence that the patient has a documented comorbidity of the spine that would require an endoskeletal knee shin system. There is also no objective evidence that indicates that the patient has abnormal right hip extension and/or quadriceps function that impairs K3 level functioning with the use of a microprocessor-controlled knee alone rather than the requested endoskeletal knee shin system with microprocessor control. In addition, the submitted documentation does not demonstrate that the patient has a regular need for long distance ambulation at variable rates, a need for regular ambulation on uneven terrain, or a need for regular use on stairs that cannot be met with an appropriately fitted standard prosthesis. Furthermore, there is no evidence of a plan and a particular job that the patient is returning to that requires the requested prosthesis for employment over a standard prosthetic device. Under these circumstances, the requested right leg prosthesis with a microprocessor is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medical device is 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 physical medicine and rehabilitation, with subspecialty certification in neuromuscular 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: Overturned

Nature of Statutory Criteria/Case Summary: An  enrollee has requested reimbursement for residential treatment services (RTC). The American Psychiatric Association (APA) treatment guidelines recommends RTC or similar care higher than outpatient is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use...lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. The records provided for review document that this patient required a safe and stable living environment in order to develop their recovery skills. Applying the American Society of Addiction Medicine (ASAM) guidelines, this patient qualified for Level III treatment, which is consistent with RTC or inpatient treatment similar to what patient received at the facility. The patients risk factors include his environment and he has limited social support. He needs time to both rehabilitate from substances but also come up with treatment for his underlying depression and anxiety. Given his rapid relapse after detoxification the month prior admission to RTC, the patient was at elevated risk for further relapses. Accordingly, the RTC services provided from 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for physical therapy. Findings:  The physician reviewer found that he Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients medical condition. The submitted documentation does not support the medical necessity of the requested physical therapy. While the patient has had ongoing symptoms, there are no indications that she has any impairments that would preclude independent management, to include low impact aerobic exercise and gentle stretching for her fibromyalgia, wrist splint(s) for carpal tunnel syndrome, and general measures such as topical heat. These are the mainstays of management for her condition, and there is no proven marginal improvement in the clinical course or outcomes with prolonged formal physical therapy over these types of independent management strategies for the patient's conditions. In this case, the patient has had various chronic pain complaints and she has undergone extensive physical therapy to address and palliate her symptoms. The patients symptoms have persisted, and there is no indication that further physical therapy would be expected to positively impact her course clinically. Under these circumstances, the requested physical therapy is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested physical therapy is 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 physical medicine & rehabilitation 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:  The enrollee requested reimbursement for gene panel testing. The enrollee is a pregnant female who underwent gene panel testing for autosomal recessive and X-linked genetic conditions.  The treating obstetrician indicated the test results would play a critical role in the enrollees decision to elect or decline an invasive diagnostic procedure, which presents a small risk of miscarriage, but would allow for prompt referral to appropriate specialists.  Findings: The physician reviewer found that  the enrollee was found to be a carrier for Usher syndrome, type IIA. Genetic counseling was provided, which included an explanation of the risks of having an affected child.  The father of the baby was then tested for Usher syndrome with negative results. The medical literature indicates clinical experience and information regarding the utility of expanded carrier panels is limited and currently under investigation An extensive joint statement in the medical literature specifies information related to criteria for conditions to be included on expanded carrier panels, recommendations related to interpretation of molecular findings, as well as needs for further data collection and research. They indicate the proper selection of appropriate disease-causing targets for general population-based carrier screening should be developed using clear criteria, rather that simply including as many disorders as possible. There is ongoing research regarding the role of expanded carrier panels and the impact on reproductive outcomes is expected to be available in the future when the panels are more focused and standardized. The conditions tested are intended to be significant, meaning that they cause a problem for a child.  Currently, however, expanded carrier screening is testing for a large number of conditions that do not meet these criteria. This enrollee has no personal or family history suggestive of an increased risk of a significant genetic disorder that would meet criteria for testing.  Expanded carrier panels are not currently the standard of care. Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any other available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in Obstetrics and Gynecology 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: Medical Necessity
Decision: Overturned

A 54-year-old male enrollee has requested a pancreas transplant for the treatment of his condition. Findings:  The physician reviewer found that the patient is an appropriate candidate for pancreas-kidney transplantation and there is sufficient evidence of the procedures efficacy to support its use in this setting. As such, the requested pancreas transplant is medically indicated for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Actemra infusions. Ringold and colleagues noted that, in patients with JIA and polyarthritis and moderate or high disease activity receiving a first tumor necrosis factor inhibitor (TNFi) (with or without disease-modifying anti-rheumatic drugs), switching to a non-TNFi biologic (tocilizumab or abatacept) is conditionally recommended over switching to a second TNFi. In this case, the patient has active JIA with mild swelling in multiple joints and advanced disease with flexion contractures in both elbows and left leg. Given that she tried and failed treatment with a TNFi, Humira, a non-TNFi biologic, such as Actemra, is medically indicated. Therefore, Actemra 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 rheumatology 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 91-year-old female enrollee has requested for Inderal for treatment of her migraines. Findings:  The physician reviewer found that a review of the peer reviewed medical literature regarding migraine preventives shows that a variety of agents, including beta blockers and neuro-modulators, can be beneficial. Beta blockers are known to be helpful in the prophylactic treatment of migraines and several clinical trials have confirmed that propranolol is effective in the treatment of migraines. Generic medications are required to have tolerances for bio-availability that are very close to that of the brand agent, though they may have a difference in binders and other inactive ingredients. They are generally acceptable for most patients, though for disorders such as epilepsy, where consequences of slight variance of blood levels may result in treatment failure, brand medications may be necessary. While there is no literature showing that brand name Inderal is materially different in migraine prevention than its active ingredient, propranolol, this patient has been treated effectively with Inderal.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: This patient is a 47-year-old male with a history of disc herniation at L5-S1 who is status post microdiscectomy at that level.  He has attempted conservative measures without complete relief of his back pain. In June 2005 he had a positive discogram at L5-S1. He has now requested authorization for artificial disc replacement at L5-S1. The Health Plan has denied authorization citing the experimental nature of the procedure.The proposed artificial lumbar disc replacement is an experimental procedure without established safety and efficacy. There is no Class I long-term data demonstrating an advantage to disc replacement over fusion. The long-term safety profile is unknown and complications may be severe. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 47-year-old man who has degenerative disc disease at L5-S1.  He underwent microdiscectomy in 2004 but still has severe lower back pain.  His provider has recommended artificial disc replacement surgery and authorization was requested. The Health Plan considers the procedure experimental/investigational, and authorization was denied.Despite its investigational use in Europe, the benefit of artificial disc replacement remains unproven. It has been associated with multiple severe and often catastrophic clinical events and numerous clinical failures. It remains unproven as a technique and the technology is without proven clinical value. Additionally, there is no viable revision strategy should this device fail. This is a particular concern in patients with a previously failed spinal surgery such as this one. For these reasons, I have determined 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.Physician 3: The patient is a 47-year-old male with discogenic, low back pain at L5-S1 confirmed by discography. He has tried and failed conservative treatments and is now requesting authorization for artificial disc replacement to resolve his back symptoms.  The Health Plan deems the procedure experimental/investigational and authorization and coverage were denied.Artificial disc replacement is a novel surgical option for the management of discogenic lower back pain.  To date, there is no long-term data supporting the benefits of this procedure over more conventional surgical interventions such as fusion, and it is not the standard of care for management of discogenic pain.  Long-term safety and efficacy studies are lacking in the peer-reviewed literature along with head-to-head comparison between disc replacement and interbody fusion surgery. Based upon the information set forth above, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested patent foramen ovale closure surgery for treatment of her medical condition. Findings:  Two physician reviewers found that the request for patent foramen ovale closure surgery is not likely to be more effective for this patient than other available options. This issue has been the subject of many investigations over a long period of time. Although it seems reasonable that correction of a patent foramen ovale would reduce the subsequent risk of recurrent stroke, evidence to establish a clear benefit is not conclusive and superiority to medical therapy has not been shown. Other causes for stroke sometimes are found over time after an initial conclusion that the patent foramen ovale was responsible. In sum, the requested closure of patent foramen ovale is not likely to be more beneficial for treatment of the patients medical condition than available standard therapy.  Final Result:   Two 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: All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C virus.  Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions.  Per the guidelines, treatment-naive genotype 1b patients should be treated with either Viekira Pak or Harvoni for 12 weeks. This recommendation is based on multiple high-quality clinical trials showing cure rates of over 90% and safety with either medication; the medications are U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. However, there is a lack of head-to-head trials showing that Harvoni is superior to Viekira Pak.  For these reasons, although treatment of hepatitis C is necessary in this case, the requested treatment with Harvoni for 12 weeks is not supported over the Health Plans alternative as medically necessary for the treatment of this patients hepatitis C infection.  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 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: Upheld

The patient is a 54-year-old male with a history of degenerative disc disease from L2 to S1.  He is status post laminectomy at L5-S1 and he has hypercholesterolemia. The patient has been treated with medical therapy, which includes Tylenol #3, Ativan, Neurontin, and ibuprofen. He continues to have low back pain. Upon examination sensory, motor, strength, coordination, reflexes and gait were within normal limits. The patients provider has requested authorization for epidural injection therapy. The Health Plan denied the request citing a lack of medical necessity.The patient has not undergone a recent trial of conservative therapy such as physical therapy, massage therapy or chiropractic care. He has a long-standing history of back pain. The MRI from May 2006 demonstrated multilevel degenerative disc disease and post-operative changes at L5-S1. A trial of physical therapy in combination with the current medical management might potentially provide more long-term pain relief than would be achieved with epidural injection therapy. The patient should undergo a trial of conservative therapy prior to consideration of epidural injections. 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for morphine 45 mg three times daily and Dilaudid 4 mg for breakthrough pain for treatment of the enrollee who has a history of chronic pain, progressive multiple sclerosis, and chronic abdominal pain.Findings:  The physician reviewer found that the step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative and the non-palliative settings. The Centers for Disease Control and Prevention (CDC) also states when opioids are started, providers should prescribe the lowest effective dosage. These guidelines recommend that providers should use caution when prescribing opioids at any dosage and to carefully reassess evidence of individual benefits and risks when considering increasing dosage of 50 or more MME per day. It is further recommended that providers should avoid increasing dosage to 90 or more MME per day. In this case, there is no evidence of an objective treatment goal for pain and function supporting the requested medications. Moreover, other non pharmacological ways of taking care of the pain have not been performed or addressed. There is no mention of completion of behavior therapy documented despite the pain providers recommendations and much research to support its use. Finally, not all non opioid medications have been optimized. Final Result: The reviewer determined that the requested medications 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 pain management 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 two-year-old male has requested speech therapy for treatment of the enrollees expressive language delay.  Findings:  The physician reviewer found that as noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.   Speech and language delay must be taken very seriously in young children, as the long-term consequences may be substantial.  As noted by Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. This patient has significant expressive language delay.  These deficits negatively impact his ability to communicate effectively. Studies have shown that speech and language therapy can result in significant improvement in this clinical scenario. All told, the requested speech therapy is medically necessary for the treatment of this patient.