Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the medication, growth hormone for treatment of the enrollees infertility. Findings:  The physician reviewers found that in this case, the patient did not demonstrate a history of being a poor responder to IVF therapy, and the growth hormone appeared to have been used as a routine adjuvant. Such use is not supported by the medical literature to date and should be considered investigational. Therefore, the medication, growth hormone was not likely to be superior to available standard therapy for the treatment of the patients infertility. Final Result: All three reviewers determined that the medication at issue was 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 number one, two, and three are board certified in obstetrics and gynecology with sub-specialty in reproductive endocrinology/infertility and 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 38-year-old male enrollee has requested Nexium for the treatment of his gastroesophageal reflux disease (GERD). Findings:  The physician reviewer found that there is no documentation provided necessitating the requested Nexium therapy. The submitted documentation does not indicate the degree of GERD found on endoscopy; nor is there mention of erosions, ulcer, stricture, or presence of Barretts esophagus. This documentation is necessary because the degree of erosive changes on endoscopy may determine the dosing (every day versus twice per day) and duration of PPI therapy. There is no mention in the record of a trial and failure of an H2 receptor antagonist or prokinetic agents. There is no indication of the patient requiring referral for a surgical procedure for GERD control. All told, there is no documentation provided necessitating specific therapy with Nexium. The differences between the various PPIs are not significant. There is currently a lack of evidence to suggest superior clinical efficacy of one PPI over any other. The medications display similar dose-response relationships with similar potencies and efficacies at the equivalent dose. The decision to select one PPI over another is likely to be based on the drugs licensed indication and patient tolerability. Furthermore, PPIs should be used at the lowest effective dose for the minimum duration possible and attempts to step down to a lower dose or switching to an H2 receptor antagonist periodically, to achieve the goal of minimum effective dose should take place.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee requested authorization and coverage of gastric bypass surgery with duodenal switch for the treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that gastric bypass surgery with duodenal switch is not likely to be more beneficial for treatment of the enrollees morbid obesity than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Experimental/Investigational
Decision: Upheld

A 38-year-old female enrollee has requested for an artificial disc replacement procedure for treatment of her back pain. Findings:  Three physician reviewers found that the medical literature shows that total disc replacement procedures are associated with a high rate of re-operations.  The particular device at issue is also associated with substantial morbidity and even mortality.  The safety and efficacy of this procedure over standard ones is not yet established.  Also, in this case the patient has chronic pain, but her discogram results were equivocal at best and it is noted that her pain is on the opposite side from her disc bulge.  She is unlikely to obtain benefit from the proposed surgery.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for durable medical equipment (DME) wheelchair ramp. Complex regional pain syndrome (CRPS) is a heterogeneous and poorly understood condition that can be provoked by a relatively benign inciting injury (Cutts, et al.). With respect to treatment, various pharmacotherapies and programs to desensitize patients to stimuli have been utilized to manage this condition (Baron, et al.; Kessler, et al.). However, there are few highly effective interventions available in the treatment of patients with CRPS (Duong, et al.; Urits, et al.; Kessler, et al.). The patient in this case, has been diagnosed with arthritis and CRPS. A diagnosis of fibromyalgia is also listed in the available records but was not included on the prescription form. The provider has recommended a power wheelchair to address her dysmobility symptoms and a ramp to address accessibility into the patients residence. The records document the presence of a small threshold that the patients power wheelchair is expected to have difficulty negotiating when entering her residence. It is noted that improper acceleration of the power wheelchair over the threshold risks collision of the wheelchair with the door, which is made of glass. In this clinical setting, the requested wheelchair ramp may be helpful, but it is not supported as medically necessary for treatment of this patients medical conditions based on the current medical literature. For these reasons, the requested wheelchair ramp is not medically necessary for this patient. Final Result: The reviewer determined that the requested equipment 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 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 six-year-old male enrollee has requested continued speech therapy once per week for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that this patient is still significantly behind in his articulation skills and is unintelligible at least 25% of the time. This patients articulation deficit is a neurological developmental dysfunction. The maturation of his brain circuitry has been altered so he has not developed articulated speech in a timely manner. There is a robust medical literature supporting speech therapy to improve articulation in this patient population. Tyler and Sharp state in their review of the literature, that there is good documentation supporting the necessity and effectiveness of speech therapy in children over the age of three with articulation dysfunction. This patients records indicate that he has made significant gains in these areas with one hour of speech therapy per week for one year. Based on the patients significant improvement with speech therapy, it is medically necessary that he receive one hour of individual speech therapy per week for the recommended nine months. The patient should also undergo a psychological assessment and evaluation by a developmental neurologist to confirm the diagnosis of autism. Consistent with these findings, the requested speech therapy for one hour per week is medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 48-year-old female enrollee has requested radiofrequency neurolysis, including cooled ablation for treatment of her sacroiliitis.  Findings:  Three physician reviewers found that the peer-reviewed medical literature has extensively researched sacroiliac joint to low back and lower extremity pain and it is generally accepted that approximately 10% to 25% of patients with persistent low back pain may have pain arising from the sacroiliac joints. Sacroiliac joint pain may be treated with intra-articular injections, peri-articular injections or radiofrequency neurolysis. Radiofrequency neurolysis varies from conventional heat radiofrequency neurolysis, to pulsed radiofrequency, to cooled radiofrequency neurolysis. Thus far, there is no substantial evidence for any modality, except cooled radiofrequncy neurolysis (Cohen, et al.; Patel, et al; Hawkins and Schofferman; and Liliang, et al.). In two separate randomized trials, cooled radiofrequency neurolysis was found to be effective when compared to placebo (Cohen, et al. and Patel, et al.). Other studies have shown clinically significant improvements at three and six months post-operatively in patients treated with cooled radiofrequency neurolysis, when compared to control groups (Cohen, et al.; and Patel, et al.). The patient in this case has undergone appropriate investigation of her condition and has long-standing chronic pain. Her diagnosis of sacroiliac joint pain has been confirmed utilizing diagnostic nerve blocks, making her an appropriate candidate for radiofrequency neurolysis, with cooled ablation. Thus, the Health Plans denial of the requested procedure should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for HP Acthar gel 400 units/5 mL vial. This patient has a diagnosis of multiple sclerosis. She has failed to respond to multiple medications. Acthar gel has received U.S. Food and Drug Administration (FDA) approval for the treatment of multiple sclerosis exacerbation. The use of Acthar gel is appropriate for patients intolerant to intravenous (IV) steroids. Acthar gel is clinically indicated for this patient as she has been unable to tolerate IV steroids, and has not substantially improved with several standard therapies. Given these findings, HP Acthar gel 400 units/5 mL vial is medically necessary for 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 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: Urgent Care
Decision: Upheld

A 19-year-old male enrollee has requested emergency services for the treatment of his condition. Findings:  The physician reviewer found that there is no evidence that this patient's presentation was urgent due to the infectious nature of the disease. A scabies infestation was not proven, and even if proven, is not a medical emergency. The patients request for coverage of this medical visit should be denied, as a prudent layperson would be able to identify the somewhat long-term nature of the problem and realize that treatment could wait for evaluation until the clinic hours of his regular physician. This patients symptoms do not meet the prudent laypersons criteria for an emergency.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for bilateral Euflexxa injections or Synvisc injections. Findings:  The physician reviewer found that the current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. According to a medical study, intra-articular hyaluronic acid provides a moderate symptomatic benefit to knee osteoarthritis patients without major safety concerns. In addition, another study reported on a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The latter study found that the current highest level of evidence suggests that intra-articular hyaluronic acid as a viable option for knee osteoarthritis. Viscosupplementation resulted in improvements in knee pain and function that can persist for up to 26 weeks. Given the support in the current medical literature, the requested bilateral Euflexxa injections are medically necessary for treatment of this patients osteoarthritis of the knees. 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 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 56-year-old female enrollee has requested a magnetic resonance imaging (MRI) of the right shoulder for the evaluation of her chronic shoulder pain. Findings:  The physician reviewer found that there is no clearly defined indication for an MRI of the patients right shoulder. Within the practice of Rheumatology, shoulder MRIs are usually requested because of soft tissue problems (i.e., rotator cuff abnormalities) or much less often to look for evidence of osteonecrosis of the humeral head. An MRI is rarely needed to evaluate rheumatoid joint damage itself, as the patients history, exam, and plain films typically provide the necessary information. The records submitted do not include any indication of a history suggestive of soft-tissue or joint-related problems. There is no evidence based on the documented physical examination to suggest arthritis or tendonitis as the cause of symptoms. Nor is the presence of joint effusion likely based on the records provided. All told, the clinical information provided does not support a finding of medical necessity for an MRI of this patients right shoulder.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old male enrollee requested authorization and coverage of the medication Viagra. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees erectile dysfunction.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral knee replacement surgery for treatment of the enrollees knee pain. Findings:  The physician reviewer found that this patient presents with severe bilateral knee pain with significant functional limitation in activities of daily living. Clinical examination findings are consistent with x-ray evidence of bilateral severe knee osteoarthritis. Her body mass index is 46.19, with prior weight loss efforts reported as ineffective. Detailed evidence of long-term reasonable and/or comprehensive nonoperative treatment protocol trial and failure has been submitted. She has been advised of the potential of increased complications undergoing total knee replacement due to her elevated body mass index.  She wishes to proceed with total knee replacements acknowledging that she exceeds the recommended body mass index level and there was increased risks for adverse outcome. Therefore, the requested bilateral knee replacement surgery 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 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: Experimental/Investigational
Decision: Upheld

A 63-year-old male enrollee has requested for stereotactic radiosurgery for treatment of his prostate cancer. Findings:  Three physician reviewers found that the use of stereotactic radiosurgery for the treatment of prostate cancer is relatively new, and thus follow-up is relatively short. The American Society for Therapeutic Radiology and Oncology has addressed the role of stereotactic radiosurgery for low-risk prostate cancer. They note that stereotactic radiosurgery regimens currently under investigation have only extremely short follow-up times and small numbers of patients. They also state that data at this time are inadequate to demonstrate either significant efficacy or toxicity rates. They note that further clinical trials addressing the uncertainties in the clinical implementation of this new approach to prostate cancer treatment should be conducted. At this time, the superior efficacy of stereotactic radiosurgery over alternative treatment options has not been demonstrated in this clinical situation.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old male enrollee has requested PKU cooler for treatment of his phenylketonuria (PKU).  Findings:  The physician reviewer found that documentation indicates that the patient has not been fully compliant with a low protein diet despite multiple counseling sessions. The elevated phenylalanine levels suggest noncompliance. In addition, the patient has not tried and failed appropriate dietary modification, and there are no published data that the dietary supplements contained in a PKU cooler result in improved clinical outcomes. Moreover, the available literature does not support the use of PKU cooler in patients with phenylketonuria. In summary, the requested PKU cooler is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a two-year-old male enrollee has requested authorization and coverage for Genotropin. Findings:  The physician reviewer found that although GH therapy is medically necessary for children with Prader-Willi syndrome, there is no specific brand of GH therapy that has been shown to be more effective or have a lower rate of adverse effects than another. There is no documentation that the patient had an adverse reaction to the Health Plans formulary brand of GH. GH treatment of children with Prader-Willi syndrome has been shown to improve linear growth, promote growth of lean body mass, decrease fat mass by increasing fat oxidation and total body energy expenditure, and improve cardiovascular risk factors. Complications of GH therapy in children with Prader-Willi syndrome are infrequent, and with close monitoring, GH therapy is considered safe in this patient population. Given these findings, the requested Genotropin GH therapy is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology 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 Otezla for treatment of her plaque psoriasis.  The physician reviewer found that traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of anti-tumor necrosis factor (TNF) biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus. Despite several difficulties with documenting risks, some systemic treatments for psoriasis have been linked with an increased risk of certain cancers. In addition, patients treated with anti-TNF drugs may develop adverse events such as infections, acute infusion and injection reactions, autoimmunity and cardiovascular effects. Otezla provides a novel therapeutic option for the treatment of patients with moderate to severe plaque psoriasis. Its effects on cyclic adenosine monophosphate regulated intracellular signaling, gene expression, and subsequent protein levels allow apremilast to modulate the immune responses that cause the inflammation associated with psoriasis. 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 dermatology 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency services on an emergent or urgent basis. Findings:  The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with fever, headache, chills, abdominal pain and nausea. These symptoms can indicate possible sepsis, a potentially life threatening infection. In addition, nausea precludes the ability for the patient to take oral medications such as oral antibiotics. She reported her pain rating at 10/10. Finally, the patients symptoms had been persistent for 10 days which indicates a more serious infection as most minor illnesses resolve within one week. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would reasonably believe she was suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the ED services met prudent layperson criteria for emergency care. Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in emergency 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.