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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Velphoro (sucroferric oxyhydroxide). Researchers note that a prescription of sucroferric oxyhydroxide as monotherapy to phosphate binder (PB) naive patients, or in addition to existing PB therapy, is associated with significant improvements in serum phosphate control and a low daily pill burden. In this case, the patient has failed conventional therapy with sevelamer, and calcium binders are contraindicated due to his borderline hypercalcemia. In this clinical setting, the requested medication is medically indicated for management of secondary hyperparathyroidism in this case. Therefore, Velphoro (sucroferric oxyhydroxide) 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 nephrology 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 three-year-old male enrollee has requested speech therapy and occupational therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that the patient is diagnosed with autism and has a history of an expressive and receptive language delays with socialization and pragmatic deficits.  Language deficits are one of the core aspects of autism and speech therapy provides professional help and guidance on communication development for individuals with autism (Volmar and Wiesner).  Language skills make a significant difference in the ability of children to control their environment, especially in patients with social skills deficits (Goldstein). This patient will benefit from speech therapy as part of a dedicated intervention program. Goldstein also reviewed communication intervention for autism in peer-review literature and found evidence supporting the claim that effective interventions exist to teach communication skills to children with autism. Therefore, the requested speech therapy is medically necessary, at a frequency of one hour per week, for treatment of the patients speech delays.  In regards to the requested occupational therapy for this patient with age-appropriate fine motor skills, the requested occupational therapy is not medically necessary. Occupational therapy is indicated when deficits exist in functional skills or occupational performance in the areas of play and leisure, self-maintenance, school tasks, or activities of daily living (Baranek and Case-Smith, et al.). The peer reviewed medical literature offers strong positive evidence for occupational therapists to use comprehensive, individualized analysis of a patients performance to develop intervention strategies when delays are noted (Baranek and Case-Smith, et al.). In this case, the patient was not noted to have significant deficits in the areas of play and leisure, self-maintenance or activities of daily living.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for tolerance induction program (TIP). The Food Allergy Practice Parameters state that, Although immunotherapeutic approaches, such as oral immunotherapy, in clinical trials show promise in treating food allergy, they are not ready for implementation in clinical practice at the present time because of inadequate evidence for therapeutic benefit over risks of therapy . The standard of care is strict avoidance of peanut. Epinephrine auto injectors are used for the treatment of reactions due to accidental ingestions. The U.S. Food and Drug Administration (FDA) recently approved peanut allergen oral immunotherapy powder. However, data has shown that patients may have severe reactions, even on maintenance doses. Wasserman and colleagues concluded that, Peanut oral immunotherapy carries a risk of systemic reactions. Due to difficulty determining the effects of oral immunotherapy, significant adverse reactions to doses and potential of developing eosinophilic esophagitis, the world experts on food allergy agree that food oral immunotherapy should remain limited to clinical research settings. In this case, the request is for tolerance induction program (TIP) or sustained unresponsiveness. The goal of the TIP is to administer higher doses to allow for addition to the diet. The plan is to also add other foods for which there are no standardized protocols. The guidelines continue to recommend allergen avoidance but allow for oral immunotherapy and now there is FDA approved medication for peanut oral immunotherapy. There is a lack of recommendations, national guidelines or large randomized controlled trials to support an indication for TIP over standard avoidance and use of epinephrine. All told, the requested TIP is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested TIP is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in allergy and  immunology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 50-year-old female enrollee has requested authorization and coverage for the medication Xyrem for treatment of the enrollees narcolepsy.  Findings:  The physician reviewer found that At issue in this case is whether the requested medication Xyrem is medically necessary for treatment of the enrollees medical condition.Xyrem is Food and Drug Administration approved for treatment of two common symptoms of narcolepsy: excessive daytime sleepiness (EDS) and cataplexy. Alshaikh and colleagues noted that narcolepsy patients on Xyrem had significant reductions in cataplexy and daytime sleepiness. Xyrem is well tolerated in patients with narcolepsy, and most adverse events were mild to moderate in severity. Boscolo-Berto and colleagues through meta-analysis of multiple peer reviewed studies demonstrated the effectiveness of Xyrem in treating major, clinically relevant narcolepsy symptoms and sleep architecture abnormalities.The medical records indicate the patient has narcolepsy and has been treated with other treatments without sufficient response. Xyrem is a consideration given failure or incomplete response to other treatments to date.  Therefore, Xyrem is medically necessary for the 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 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: Experimental/Investigational
Decision: Upheld

A 44-year-old male enrollee has requested radiofrequency tissue shrinkage of the palate and base of the tongue for treatment of his obstructive sleep apnea.  Findings:  Three physician reviewers found that a polysomnography performed  showed an apnea/hypopnea index (AHI) of 43.7 and the patient was reportedly unable to tolerate the continuous positive airway pressure (CPAP) mask.  Based on the evidence provided, the patient only tried the CPAP machine once during the sleep study. Ideally, the patient should undergo an adequate trial with CPAP prior to resorting to other more invasive modalities of treatment such as surgery. Since this patients sleep apnea is moderate-to-severe, he is not likely to achieve superior results from surgical interventions. The best outcomes in this setting result from CPAP therapy.Although Eun and colleagues suggested that radiofrequency tongue base reduction in combination with radiofrequency palatal reduction can help patients with multilevel obstruction, this study was performed without adequate controls. Some studies have concluded that patients treated with uvulopalatopharyngoplasty (UPPP) fared no better when compared to patients treated with UPPP and radiofrequency tongue base reduction in terms of reduced AHI. In conclusion, the requested surgery is not likely to be more beneficial for treatment of the patient's medical condition than any available standard therapy.
Appeal type: Urgent Care
Decision: Upheld

A 50-year-old female enrollee has requested emergency services for treatment of her medical condition. Findings:  The physician reviewer found that the patient was evaluated in the Emergency Department for worsening right shoulder pain for the past week. Her pain had increased over the past two days. The pain radiated down to her elbow. The patient denied any recent trauma, but did admit to heavy lifting on a daily basis. The patient had been using pain medication without relief. She denied chest pain, shortness of breath, headache or neck pain. The patient was alert and appeared in no acute distress. She exhibited tenderness to palpation of the right acromioclavicular joint and right clavicle. No effusion or soft tissue swelling was noted. Strength and neurovascular examinations were normal. The patient was diagnosed with tendonitis and discharged. An emergency is the sudden onset of symptoms of such severity that a prudent layperson would believe her health to be in jeopardy without immediate medical attention. This patients symptoms had been present for the past week. Although she did report increased severity of her symptoms over the past two days, the patient denied any specific trauma. She denied any acute neurologic problems as well. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. The patient could have safely waited to be evaluated by her primary care provider. The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize her health in this clinical situation.
Appeal type: Experimental/Investigational
Decision: Overturned

A 31-year-old female enrollee has requested a sleeve gastrectomy for treatment of her obesity. Findings:  Two physician reviewers found that this patient can benefit from weight loss surgery. The sleeve gastrectomy has been performed as a part of the duodenal switch operation for many years.  There is sufficient data demonstrating the benefits of the sleeve gastrectomy.  The advantage of the sleeve gastrectomy over the Lap-Band is that the sleeve gastrectomy does not involve the placement of a foreign object and does not require constant monitoring and adjustment.  In this patients case, the requested sleeve gastrectomy is likely to be the most efficacious treatment alternative.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested magnetic resonance imaging (MRI) of the brain stem without dye for evaluation of his medical condition.  The physician reviewer found that the patient has had obstructive sleep apnea, treated with improvements in apnea, but with continued reduced sleep efficiency.  The medical records document continued fatigue.  However, the documentation does not indicate that medical causes of fatigue, such as anemia, hypernatremia or hypothyroidism, have been evaluated.  The medical literature indicates a greater chance of dementia and stroke in patients with sleep apnea.  Additionally, there is an association with central apnea and brain pathology, but no particular causal relationship is cited to indicate that obstructive sleep apnea is caused by brain pathology.  No neurologic examination was provided to suggest focal clinical signs, for which there would be reasonable expectation of brain pathology.  Thus, the requested MRI of the brain stem is not likely to lead to changes in treatment and is not medically indicated for the evaluation of this patient.  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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for Residential Treatment Center (RTC) level of care services. Findings:  The physician reviewer found that At issue in this case is whether any or all of the Residential Treatment Center (ASAM 3.5) level of care services at issue and requested services were, and are, medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A) to treat the enrollees mental health or substance use disorder.American Society of Addiction Medicine (ASAM) level 3.5 criteria focus on six dimensions to determine the appropriate level of care. In this case the patient meets the criteria for ASAM dimension 1 (Acute Intoxication and/or Withdrawal Potential), dimension 2 (Biomedical Conditions and Complications), dimension 4 (Readiness to Change), and dimension 6 (Recovery Environment). However, the patient does not meet the criteria for dimension 3 (Emotional, Behavioral, or Cognitive Conditions and Complications) or dimension 5 (Relapse, Continued use, or Continued Problem Potential). Therefore, the patient does not meet the specifications for each of the six dimensions for medical necessity.The patients scores under the six ASAM dimensions consider the specific needs of the patient for the purpose of treating their illness and its symptoms. The ASAM criteria for determining the appropriate level of care are consistent with generally accepted standards of mental health, and they provide determinations that are clinically appropriate in terms of type, frequency, extent, site, and duration. The ASAM criteria are also free from consideration of the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Accordingly, the Residential Treatment Center (ASAM 3.5) level of care services at issue and requested services were not, and are not, medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A).Final Result: The reviewer determined that the services at issue and requested services were not, and are not, medically necessary to treat the patients mental health or substance use disorder, as defined in Health and Safety Code section 1374.72(a)(3)(A). 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: Upheld

The parents of a 7-year-old female enrollee requested authorization and coverage of continued speech therapy for the treatment of autism.  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 Vyvanse 60 mg daily.The U.S. Food and Drug Administration had approved the use of Vyvanse (lisdexamfetamine dimesylate) for treatment of ADHD. Vyvanse is part of a class of long-acting agents known as prodrugs that do not rely on mechanical releases that may be affected by gastrointestinal factors, such as transit time and pH. Unlike other stimulant medications, prodrug absorption and conversion are not prone to food or drug interactions. Adler and colleagues found that among adults with ADHD and clinically significant executive function deficits, lisdexamfetamine dimesylate was associated with significant improvements in self-reported executive function ratings. In this case, the patient has been diagnosed with ADHD. He has been stable on Vyvanse, and it would be against the standard of care to stop this medication. Given that this patient is at risk of decompensation and functional decline without his current medication, Vyvanse is medically indicated for this patient. Therefore, Vyvanse 60 mg daily 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 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 Pyridium (phenazopyridine) 200 mg. for treatment of her chronic interstitial cystitis. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication. A review of current literature and treatment guidelines fails to show Pyridium (phenazopyridine) at any dose is effective of the amelioration of interstitial cystitis symptoms and it is not commonly considered in treatment algorithms. Based on the patients history, Pyridium (phenazopyridine) appears symptomatically valuable for this particular patient. However, there is a lack of medical literature to support any substantive difference between two over-the-counter Pyridium (phenazopyridine) 97.5 mg tablets, as recommended by the Health Plan and one prescription Pyridium (phenazopyridine) 200 mg tablet with regard to equivalence in bioavailability or likely treatment effect. All told, the medical necessity of the requested medication has not been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee has requested Botox injections for the treatment of her muscle spasm and dystonia. Findings:  Two physician reviewers found that the clinical data submitted for review is consistent with a complex regional pain syndrome. There is no documentation of cervical dystonia and the original Botox therapy was for pain in the right axilla. There are multiple standard therapies that have not been explored, including desipramine, Lamictal, Keppra, and Tegretol.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for SpaceOAR hydrogel placement. Hydrogel spacers may be used during radiation treatment of the prostate to increase the space between the rectum and prostate and to decrease the amount of radiation that is delivered to the rectum. In a randomized, phase III trial of patients undergoing radiation therapy for prostate cancer, Hamstra and colleagues found a benefit in the use of a hydrogel spacer in reducing adverse effects, rectal dose, toxicity, and quality-of-life declines related to bowel and sexual side effects. National Comprehensive Cancer Network (NCCN) guidelines endorse the use of a hydrogel space in patients undergoing radiotherapy for prostate cancer. Therefore, SpaceOAR hydrogel placement was likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the SpaceOAR hydrogel placement at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

An 18-year-old female enrollee has requested for Keppra XR 500 mg for treatment of her seizures. Findings:  The physician reviewer found that studies of Keppra immediate release (IR) show a 17-30% reduction in seizures over placebo, depending on dosage. Keppra IR has similar efficacy as Keppra XR, though it requires BID dosing. Keppra XR does not have data showing greater effectiveness in general than Keppra IR.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 47-year-old woman with a history of non-specific back and neck pain. The patient underwent cervical fusion in February 2004. She continues to experience leg and low back pain. The patients provider has recommended L5-S1 fusion surgery. The patient has requested authorization and coverage for spinal fusion surgery and a discogram. The Health Plan has denied the request on the basis that the requested services are not medically necessary for treatment of the patients medical condition.There is no clear indication for either a spinal fusion or discogram at this time. The submitted evidence reveals no evidence of disc degeneration or any other abnormality. Without conclusive identification of the etiology of the patients pain, surgery is not indicated. Continuation of conservative treatment is medically reasonable and appropriate. Therefore, I have determined that the requested services are not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.