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

A 49-year-old male enrollee has requested for variegate porphyria (VP) testing and hereditary coproporphyria (HCP) testing for evaluation of his suspected porphyria. Findings:  The physician reviewer found that current Medical Diagnosis and Treatment, is unexplained abdominal pain, generally in young women, acute peripheral or central nervous system dysfunction, recurrent psychiatric illnesses, hyponatremia, and porphobilinogen in the urine during an acute attack. The porphyria that usually presents in adulthood is acute intermittent porphyria (AIP), which is inherited as an autosomal dominant, though it remains clinically silent in most patients who carry the trait. The diagnosis may be elusive if not specifically considered. The disorder is caused by partial deficiency of porphobilinogen deaminase activity, leading to increased aminolevulinic acid and porphobilinogen in the urine. Attacks are precipitated by numerous factors including drugs and infections. Hyponatremia may be seen, due in part to inappropriate release of antidiuretic hormone, although gastrointestinal loss of sodium in some patients may be a contributing factor.This patient has been evaluated by multiple specialists in psychiatry and has no evidence of a diagnosis of porphyria.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 9-year, 11-month-old female enrollee has requested Genotropin growth hormone (GH) therapy for treatment of the enrollees short stature.  Findings:  The physician reviewer found that according to the Lawson Wilkins Pediatric Endocrinology Society recent guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests with a height more than 2.25 SDs below the mean for age or more than 2 SDs below the mid-parental height percentile, a growth velocity less than the 25th percentile for bone age, a bone age more than 2 SDs below the mean for age, low serum IGF-1 and/or IGFBP-3, or other clinical features suggestive of GH deficiency. This patient does not meet these criteria. This patients pre-treatment height was not more than 2.25 SDs below normal for age and gender. Therefore, she was not short enough to meet standard criteria for a trial of GH therapy for idiopathic short stature. Her adult predicted height, based on her bone age radiograph and height measurement on the said date was approximately 58 inches, which is within 2 SDs of her mid-parental target height. Given her normal growth velocity, normal bone age, and normal growth factors, this patient does not meet criteria for classic GH deficiency. Her increase in growth velocity, as recorded shortly after initiation of GH therapy was initiated, was during early puberty when one would expect the growth rate to accelerate regardless of treatment. Thus, it has not been conclusively established what effect GH treatment had on boosting the growth rate in this patient. For these reasons, the requested Genotropin GH therapy has not been shown to be medically necessary for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee requested authorization and coverage of a referral to an infectious disease specialist. The Health Plan denied the request indicating that the requested referral is not medically necessary for treatment of the enrollees skin and fungal problems.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested referral is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a cardiac stress test for evaluation of his chronic pain and orthostatic dizziness. Findings:  The physician reviewer found that based on the records provided for review, this patient presents with no documented coronary risk factors, no symptoms concerning for angina, no cardiac physical examination abnormalities and no coronary ischemia on prior stress testing about two years ago. In this circumstance, further evaluation with repeat stress testing is not considered standard accepted practice in the medical community. Current guidelines for both stress echocardiography and nuclear stress testing that are endorsed by several national organizations also do not consider stress testing appropriate in this clinical setting. Final Result: The reviewer determined that the requested diagnostic procedure 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 internal medicine with sub-specialty certification in cardiovascular disease 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testingFindings:  The physician reviewer found that based on current American Heart Association (AHA) and American College of Cardiology (ACC) prevention guidelines, this patient is not classified as a candidate for statin therapy to reduce his cardiovascular risk given his scoring (Arnett, et al.). However, his scoring supports use of additional risk enhancing factors to further define cardiovascular risk and the need for statin therapy. Advanced lipoprotein testing was indicated for this patient to further define cardiovascular risk and to help determine whether to start statin therapy. In this patients work-up, use of advanced lipoprotein testing was consistent with the current AHA and ACC guideline recommendations and published data. Accordingly, the advanced lipoprotein testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the advanced lipoprotein testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in cardiovascular disease with subspecialty certification in interventional cardiology and is 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.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee requested authorization and coverage of discography. The Health Plan denied the request indicating that the requested discography is not medically necessary for evaluation of the enrollees back pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested discography is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Zofran. The submitted documentation fails to demonstrate the medical necessity of the requested medication regimen. There is a lack of documentation indicating the patient was treated by a physical health provider. This patient has chronic nausea associated with her medical condition. Although the patient has a diagnosis of irritable bowel syndrome and gallstones, there is a lack of documentation to support that these conditions are the cause of the patients chronic nausea. The treatment for a patient with chronic and prolonged symptoms associated with her medical condition includes medication and cognitive behavioral therapy. Medication choice typically includes a serotonergic reuptake inhibitor antidepressant. There is no indication for the medication Zofran in the treatment of her medical condition. Zofran (ondansetron) is an antiemetic, which has been approved for the treatment of chemotherapy-induced nausea and vomiting, radiotherapy-associated nausea and vomiting and postoperative nausea and/or vomiting. It has an off-label use for nausea and vomiting of pregnancy that is severe or refractory. In this case, the patient does not have a condition that is U.S. Food and Drug Administration approved for the use of this medication. Per the records, the patient has not completed formal cognitive-behavioral therapy, which is indicated for the treatment of the patients medical condition. Furthermore, the daily/chronic use of this medication has the potential to interfere with the patients psychiatric medications. Therefore, Zofran is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 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 outpatient counseling services twice per week for four months for treatment of his medical condition.   Findings:  The physician reviewer found that this patient has been diagnosed with generalized anxiety disorder, panic disorder and social anxiety. He continues to be in psychotherapy treatment which has been helpful per the subjective report. Data regarding treatment of anxiety disorders suggests that the key targets for improvement in treatment adequacy include regular follow-up of patients with a generalized anxiety disorder medication and access to psychotherapy. The patients preference should be considered in the choice of treatment and drug treatment should be continued for up to one year after remission. If psychotherapy or drug treatment is not adequately effective, then the treatment should be switched to the other form, or to a combination of both. In this case, the patient does not want to take psychotropic medications for anxiety. Psychotherapy can be continued alone. However, the request for outpatient counseling treatment twice per week for four months is excessive and therefore 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.  Qualifications/Credentials: 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: Experimental/Investigational
Decision: Upheld

A 54-year-old female enrollee has requested lumbar artificial disc replacement for treatment of her degenerative disc disease. Findings:  Three physician reviewers found that there is a lack of medical literature demonstrating the long-term safety and efficacy of the procedure at issue. In one case series study with longer follow-up, Shim and colleagues followed 24 patients for greater than three years and concluded that the facet joint of the index level and the disc at the adjacent level showed an aggravation of the degenerative process in a significant number of patients (32% and 28.6%, respectively), raising concerns of possible late consequences of total disc replacement, especially regarding facet arthrosis and adjacent segment disease.  Given the overall lack of long-term safety and efficacy data, the procedure at issue was not likely to have been of greater benefit than other available treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 42-year-old female who weighs 256 pounds and is 52 with a BMI of 47. In addition, she has comorbid conditions of hypertension and asthma. She has undergone a psychological evaluation and is considered an appropriate candidate for bariatric surgery. She has requested authorization and coverage for gastric bypass surgery.With a BMI of 47 the patient meets nationally accepted criteria for consideration of weight loss surgery. In addition, it is unlikely that the patient will be able to lose weight and maintain the weight loss through non-surgical means. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese. Furthermore, the patient has undergone an appropriate psychological evaluation and is considered an appropriate candidate for weight loss surgery.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Urgent Care
Decision: Overturned

The parent of a 10-year-old male enrollee has requested for emergency services for treatment of the enrollees gastrointestinal symptoms. Findings:  The physician reviewer found that The patients symptoms met prudent layperson criteria for emergency care. A prudent layperson parent with an average knowledge of medicine and a child with symptoms of nausea/vomiting/cramping would reasonably expect the absence of emergency care to jeopardize the patients health. Although the family was apparently very concerned about toxic mold exposure, these symptoms can represent other more common and serious illnesses in children, such as gastrointestinal bleeding, infection, inflammatory bowel disease, kidney stones, urinary tract infection, appendicitis, or bowel obstruction. In addition, poor oral intake accompanied by vomiting can easily result in dehydration and progression of dehydration can have serious consequences.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested 12 weeks of Harvoni for treatment of her hepatitis C.   Findings:  Two physician reviewers found that per the current medical evidence, an accurate assessment of fibrosis is vital in assessing the urgency for treatment.  Based upon American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, treatment is recommended for all patients with chronic hepatitis C infection, except patients with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  Immediate treatment is assigned the highest priority for those patients with compensated cirrhosis, advanced fibrosis, liver transplant recipients, and patients with severe extrahepatic hepatitis C.  In this patients case, a recent fibrosis stage is needed in order to establish the medical necessity of the requested medication.  All told, the requested 12 weeks of Harvoni is not medically indicated for the treatment of this patient.  Final Result:  Two reviewers 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 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.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 11-year-old male enrollee has requested speech therapy for treatment of the enrollees stuttering disorder. Findings:  The physician reviewer found that despite years of community and school based speech therapy the patient continues to stutter. The patients speech therapist reported a 70% speech dsyfluency and the child psychiatrist assessed the patient as a stutterer. Intensive speech therapy is necessary to prevent stuttering from becoming a lifelong disability. Based on an extensive survey of children in North Carolina, spontaneous remission from stuttering is the exception not the rule, and that the chance of recovery from stuttering diminishes with age (Kalinowski, et al). Without intensive speech therapy this nearly 12 year-old patient has little chance of improvement from stuttering. The patients Tourettes syndrome, associated tics and ADHD compound his poor potential for spontaneous improvement. Yanuss and colleagues provide an overview of the current therapies that are effective in helping children improve their speech fluency and diminish the negative effects of the disorder; the authors conclude, speech-language pathologists can help children increase their fluency while simultaneously minimizing the adverse impact of their speaking difficulties and helping them improve their overall communication. Furthermore, Onslow and OBrien emphasizes that intensive and early speech therapy intervention is necessary before stuttering becomes intractable. Stuttering in an adult can cause profound psychological, social, educational, and occupational problems (Onslow and OBrien). A meta-analysis of the reviewed literature reported that children who receive speech therapy are 7.7 times more likely to have resolution of their stuttering than non-treated children (Onslow and OBrien). The lack of obvious structural abnormality does not negate the fact that this patients stuttering has its origins in the structural failure of the neurological development of speech. It is medically necessary that this patient receive individual speech therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Mavyret (glecaprevir-pibrentasvir) 100-40 MG tablets for eight (8) weeks. The American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (ISDA) includes Mavyret  among recommended therapies for treatment-naive patients with hepatitis C, genotype 1b, without cirrhosis. In this case, the patient has a diagnosis of hepatitis C, genotype 1b. Given current medical guidelines, and as the documentation does not reflect any contraindications, the requested medication is medically indicated. Therefore, the requested Mavyret (glecaprevir-pibrentasvir) 100-40 MG tablets for eight (8) weeks 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 infectious disease 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: The patient has requested authorization and coverage for Fentanyl 100 mcg/hr patch every 48 hours. The Centers for Disease Control and Prevention (CDC) guidelines state that nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. The Federation of State Medical Boards guidelines noted that opioid therapy for chronic pain that is not cancer-related, or part of palliative care, is recommended only when non-opioid and non-pharmacological options have not been effective and clear and objective outcomes are being met. In this case, the patient is already on high dose opioid therapy with a daily morphine equivalent dose of 255 mg per day. The CDC states that morphine equivalent doses above 90 mg are considered high dose. In this clinical setting, the CDC recommends that providers re-evaluate opioid therapy and determine if non-pharmacologic treatments can be used as an alternative. The providers notes state that the current treatment plan includes weaning the patient off opioid therapy. All told, the requested Fentanyl 100 mcg/hr patch every 48 hours is 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 is board certified in anesthesiology with subspecialty 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.