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

The patient is a 61-year-old female with reactive airway disease, IgE mediated rhinitis, chronic sinusitis and seasonal and perennial allergies related to mite, mold and animal dander. She has moderate to severe asthma which is steroid dependent and her condition is deteriorating. The patient also has an evolving depression that is situational, secondary to her chronic allergic disease and its effect on her lifestyle and well-being. Her providers note of July 2006 indicates she is broadly allergic, mostly housebound and unable to tolerate therapeutic dosages of immunotherapy. The proposed treatment involves stabilization with Xolair over several months followed by immunotherapy. If the immunotherapy is better tolerated and she is able to reach maintenance status, the Xolair could be tapered off after six to twelve months. The hope is to eventually maintain stability with standard immunotherapy and routine medications.A consultation report from May 2006 noted wheezing, chest tightness, cough and dyspnea twice weekly despite multiple medications including Advair, Singulair, albuterol and antihistamines. The provider also noted the patient had four visits to the emergency room last year and has used oral prednisone and Kenalog multiple times in the past six months.  The clinical record indicates the patient has been compliant with all of her prescribed medications. Pulmonary Function testing dated June 2006 revealed a pre-bronchodilator FEV1 of 84% and a post-bronchodilator FEV1 of 97% and laboratory testing from May 2006 demonstrated a total IgE of 755 Iu/ml.The patients request for authorization of Xolair was denied by the Health Plan based upon a determination that the therapy is not medically necessary.Treatment with Xolair is medically necessary for this patient for several reasons. First of all, the record indicates the patient has received optimal medical care and has adhered to the prescribed treatment, yet her condition has worsened. Her quality of life is severely impaired and there is concern regarding the systemic effects of higher doses of corticosteroids. Secondly, the patients provider has documented that the patient was on appropriate steroid therapy and under fairly good control due to avoidance of allergen triggers when she was unable to demonstrate an FEV1 of less than 80%. Nonetheless, her FEV1 reversibility was 15%. Lastly, the manufactures requirement that patients have an IgE of less than 700 Iu/ml was an inclusion criteria for Phase I and II clinical trials and was not intended to preclude treatment in patients with an IgE greater than 158 Iu/ml.  This patients clinical condition warrants treatment with Xolair and its use is consistent with the standards of good medical practice. Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for osteopathic manipulation treatment. A study found studies have demonstrated that osteopathic manipulative treatment has proven beneficial in providing pain relief and improved thoracic motion in patients with costochondritis, costovertebral joint dysfunction, and poststernotomy rib dysfunction. Researchers report that costochondritis refractory to conservative management may have a beneficial response to osteopathic manipulative treatment and tissue mobilization. In this case, the records demonstrate that osteopathic manipulative treatment has proven effective in the past. In this clinical setting, the requested services are medically indicated for the treatment of the patients costochondritis. Therefore, osteopathic manipulation treatment is 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 occupational 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 Harvoni for treatment of her 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 (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. AASLD guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni  is supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result:  The physician reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xyrem solution (sodium oxybate).  The submitted documentation fails to demonstrate the medical necessity of the requested medication. This enrollee reported sleep issues and mood symptoms. The progress notes do not indicate the patient has a diagnosis of narcolepsy. The requested medication is approved by the U.S. Food and Drug Administration (FDA) for narcolepsy.  There is a lack of support for the requested medication in this clinical setting. Therefore, Xyrem solution (sodium oxybate) is not medically necessary for the treatment of this enrollee. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be upheld.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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested magnetic resonance imaging (MRI) of the right knee and knee surgery for evaluation and treatment of the enrollees medical condition. Findings: The physician reviewer found that an MRI is supported if additional imaging is necessary or internal derangement is suspected. The American College of Radiology imaging criteria for non-traumatic knee pain state that the initial imaging examination for non-traumatic knee pain is radiography. An MRI examination for non-traumatic knee pain is indicated when the pain is persistent and conventional radiographs are non-diagnostic or when additional information is necessary before instituting treatment. Therefore, in this patient, the MRI is medically necessary as adjunctive diagnostically and potentially to affect treatment.  Regarding the requested knee surgery, the American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines for knee osteoarthritis generally recommend conservative treatment of osteoarthritis of the knee including weight loss for patients with body mass index greater than or equal to 25, self-management programs, strengthening, low-impact aerobic exercises, and neuromuscular education; and engaging in physical activity consistent with national guidelines. The AAOS does not recommend performing arthroscopy with lavage and/or debridement in patients with a primary diagnosis of symptomatic osteoarthritis of the knee.  Peer-reviewed evidence based medical guidelines do not support arthroscopic surgical treatment of knee osteoarthritis and support knee joint replacement for select patients with severe osteoarthritis failing conservative treatment. This patient presents with a fairly recent onset of right knee pain and swelling. The clinical exam findings show a range of motion greater than 90 degrees, mild effusion, and medial joint line tenderness. However, the specific surgical procedure has not been identified in detail. Therefore, the requested right knee surgery is not considered medically necessary.  All told, the medical records demonstrate the medical necessity of an MRI for more definitive evaluation of this patients medical condition; but, the medical records do not support the medical necessity for knee surgery.Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Specifically, an MRI of the right knee is medically necessary. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery 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 55-year-old male enrollee requested reimbursement for previous and authorization for prospective skilled nursing facility (SNF) services and/or skilled nursing facility rehabilitation services for treatment of his medical condition status post cerebral vascular accident (CVA). Findings: The physician reviewer found that in the medical literature there are limited studies on the outcomes for comprehensive programs in treating this patient population. The newer literature focuses on testing new techniques, but overall the data on patient outcome following a hemorrhagic stroke has been stable for over a decade. Essentially the research supports clear benefits of stroke rehabilitation with early intervention. There is little improvement with later treatment (Ronning and Guldvog). In addition, more than three months following a stroke, there were no substantial advancements in hospital versus settings (Anderson and colleagues). This patients stroke prevents him from clinically benefitting from daily skilled therapy. Therefore, the skilled nursing care at issue has not been established as medically necessary for treatment of this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee has requested magnetic resonance imaging (MRI) guided high intensity focused ultrasound ablation for the treatment of her uterine fibroids. Findings:  Two physician reviewers found that this patient is clearly symptomatic from her fibroids and requires treatment. Hysterectomy, myomectomy, and now uterine artery embolization (UAE) are approved and supported in the medical literature as non-investigational treatments for symptomatic fibroids. MRI guided high intensity focused ultrasound ablation is a promising treatment for symptomatic fibroids. Short-term studies suggest it is safe and effective. However, studies are still underway to determine the procedures long-term safety and efficacy. At this time, there is not adequate data from which to conclude that MRI guided high intensity focused ultrasound ablation of fibroids is likely to be more efficacious in the long-term than the alternatives mentioned.
Appeal type: Medical Necessity
Decision: Overturned

A 37-year-old female enrollee has requested CT scans of the abdomen and chest for evaluation of her stomach and back pain. Findings:  The physician reviewer found that the indications for a CT scan are rather elemental. Per American College of Radiology guidelines, abdominal pain is a sufficient symptom for evaluation by CT scan.  Furthermore, imaging of the left upper quadrant can be limited with ultrasound because of bowel gas, and CT is almost always superior to ultrasound in this area.
Appeal type: Medical Necessity
Decision: Upheld

The patient is requesting coverage for fertility treatment with intrauterine insemination. The patient reports she has made multiple attempts at intracervical insemination, which were unsuccessful, and the next step is intrauterine insemination. The American Society for Reproductive Medicine indicates infertility is a disease, defined as the failure to achieve a successful pregnancy after 12 months or more of appropriate, unprotected intercourse or donor insemination. There is no evidence that this patient is infertile as the records do not support 12 failed inseminations or an inability to conceive, despite adequate sperm exposure. She is a healthy woman, and the diagnosis of infertility is not supported without adequate sperm exposure. Only if she fails to conceive with adequate sperm exposure will she be labeled as infertile. The requested future intrauterine insemination (IUI) is not medically necessary to treat the medical condition.Final Result: The reviewer determined that the requested services are not medically necessary
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee has requested speech therapy for the treatment treatment of the enrollees speech and language delays.  Findings:  The physician reviewer found that there is an identified abnormality of the corpus callosum.  Abnormalities in the corpus callosum have been demonstrated to lead to speech and language deficits.  Early speech therapy can be of benefit for patients to improve pragmatic language skills.  The Health Plan has offered no alternative plan of treatment for the speech and language deficits.  Speech therapy goals should be objective, quantifiable and reasonably attainable within a six-month timeframe.  Progress toward the revised speech therapy goals should be reviewed by the neurologist at the end of the six-month period; if the goals are reached then therapy should proceed.
Appeal type: Medical Necessity
Decision: Overturned

A 35-year-old female enrollee has requested Lyrica for the treatment of her chronic pain. Findings:  The physician reviewer found that the patient has failed a trial of an FDA approved or medically accepted medication for neuropathic pain, and she has found relief with an anticonvulsant, Lyrica. The use of an anticonvulsant is appropriate and medically necessary as specified by Clinical Practice Guidelines for reflex sympathetic dystrophy/complex regional pain syndrome.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested  for speech therapy for treatment of the enrollees expressive language delay with phonological delay.  Findings:  The physician reviewer found that Law and colleagues, there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.The literature supports the use of speech and language therapy for verbal apraxia as well as expressive language delay. The current medical evidence has demonstrated the benefits of speech therapy in this clinical scenario.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for opiate pain relieving medication, Norco. Findings:  The physician reviewer found that there is a lack of support for the medical necessity of the requested medication in this clinical setting. Chronic pain that has no hope for a cure is considered palliative in nature and treatment. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. In the documentation available for review, not all non-opioid treatment options have been utilized. There was no mention of behavior therapy despite much research to support its use. Moreover, given the documentation of a history of emergency department visits for pain, psychiatric history, and use of illicit substances, continuation of opioid medication should be under the direct guidance of a mental health professional . Also, epidemiologic studies suggest that concurrent use of benzodiazepines and opioids might put patients at greater risk for potentially fatal overdose. The Centers for Disease Control and Prevention also states clinicians should avoid prescribing opioids and benzodiazepines concurrently whenever possible . The medical literature recommends consideration of alternatives to opioids as well as to be weaned to a lower dose of opioids or weaned off the medications entirely. In this patients case, there is a lack of objective treatment goals for pain and function for the requested medication. Finally, continuation of opioid prescribed at higher doses without proper treatment for the opioid use sets the patient up for higher morbidity and mortality. For all these reasons, the requested Norco is not medically necessary for treatment of the 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. 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: Overturned

A 51-year-old female enrollee has requested for Gleevec 400mg tablets (imatinib mesylate) for treatment of her recurrent clival chordoma. Findings:  The physician reviewer found that Gleevec can be effective in tumors with platelet-derived growth factor receptors. This apparently is present in chordomas. In view of the rarity of the tumor, there is a lack of published literature involving a large number of patients in a clinical trial. However, several small trials have shown some efficacy of the drug in chordomas. Ferraresi and colleagues treated 25 patients with chordomas with Gleevec and demonstrated some responses as well as reduction in analgesic needs in 54% of patients. Casali and colleagues noted some activity in six such patients in 2004.  The 2007 review by Casali and colleagues stated that Gleevec has been noted to be active in this tumor. There is a lack of other effective therapy options for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for skilled nursing facility level of care. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity for the services at issue in this clinical setting. Functional impairments due to acquired brain insults such as stroke can be profound. The role of inpatient rehabilitative care for persons with significant functional deficits, as in this patients case, following stroke is relatively well-established in the medical literature.  In the present case, the patient has had multiple strokes.  The records indicate that she has chronically been at the total assistance level of care since admission to the facility. The records also note that this patient has been unable to participate meaningfully in therapies. While she has chronic skin issues, this patient does not require skilled nursing services. Overall, the record demonstrates that her needs can be met at a custodial level of care.  The need for skilled nursing facility level care has not been established in this patients case. Therefore, the requested services at a skilled nursing facility level of care are not medically necessary.  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 physical medicine and 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: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee has requested a bone density study for evaluation of her multiple osteochondromatosis. Findings:  The physician reviewer found that the scientific literature does not reveal a link between osteoporosis and solitary/multiple osteochondromatosis. Although osteoporosis has been reported in association with unusual metabolic diseases (Faggiano and colleagues), there is no evidence that patients with multiple osteochondromatosis are at any greater risk of developing osteoporosis. Given the absence of an association between osteoporosis and osteochondromatosis, there is no clinical indication for a bone density study in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested for individual psychotherapy treatments for treatment of her behavioral health issues.  Findings:  The physician reviewer found that the APA states that, Cognitive-behavioral therapy is a time-limited treatment (generally 10-15 weekly sessions) with durable effects. Further, Cognitive-behavioral therapy for panic disorder generally include psycho-education, self-monitoring, countering anxious beliefs, exposure to fear cues, modification of anxiety-maintaining behaviors, and relapse prevention. All told, individual psychotherapy is likely inadequate to assist this patient through the difficult issues of anxiety disorders including anxiety, panic, phobia and sleepwalking. For these reasons, the patient appears to be appropriate for a partial hospitalization program (PHP) and the medical necessity of the requested outpatient psychotherapy has not been established in her care.