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

A 50-year-old female enrollee has requested an electric scooter for the treatment of her impaired mobility. Findings:  The physician reviewer found that the submitted clinical evidence does not support the medical necessity of an electric scooter. The patient can independently ambulate within her house. In addition, the patients neurological physical examination demonstrated excellent strength with only minimal weakness on manual muscle testing and an electric mobility device is not indicated in this situation absent some other co-morbidity (such as a severe cardiomyopathy). In fact, an electric mobility device is contraindicated in this patients situation since an electric scooter would likely promote deconditioning, and thus worsen the patients underlying physical strength and cardiopulmonary endurance. Furthermore, although the medical records indicate that this patient reports that she is unable to propel a manual wheelchair due to numbness in her arms or fatigue in her arms, specific objective sensory deficits were not noted on exam. Finally, there is no documentation in the medical records of an actual manual wheelchair trial or physical/occupational therapy assessment using a manual wheelchair in the community, as would be the standard of care prior to progressing to an electric mobility device.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old male enrollee has requested Focalin XR, at a dosage of 40mg daily for treatment of the enrollees attention-deficit/hyperactivity disorder (ADHD).  Findings:  The physician reviewer found that the clinical use of Focalin XR for the treatment of ADHD is often off-label with a higher dosage prescribed if the patient is healthy and has no reported cardiovascular or other side effects. In this case, the off-label prescription of Focalin XR was carefully documented and a dosage of 40mg daily was found to be effective. The treatment of ADHD in adolescence is a frequent exception to the FDA guidelines. When all other medications have failed and the patient responds to the higher dosage of Focalin XR without side effects, it is a common practice to prescribe a higher dosage, which appears to be indicated in this instance. When a dosage in excess of 20mg daily is prescribed, blood pressure and pulse should be monitored during each encounter with the prescribing physician and the presence or absence of any potential side effects should be assessed.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old male enrollee has requested for additional mechanical traction treatment of the lumbar spine (20 visits) for treatment of his chronic low back pain. Findings:  The physician reviewer found that there are studies that have shown that some subgroups of low back patients can benefit from mechanical traction (see Fritz and colleagues). However, some studies have shown that there is no objective benefit from mechanical traction in patients with low back pain (see Schimmel and colleagues). Although there is uncertainty in the medical literature and a need for further studies in regards to the efficacy of mechanical pelvic traction therapy, given this patients positive response to a regimen that included mechanic pelvic traction in the past, he should receive an additional 10 sessions of traction with the requirement that his provider provide thorough objective pre- and post-therapy functional ability and pain measurements.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Pegasys for treatment of her essential thrombocythemia.  The physician reviewer found that essential thrombocythemia is a myeloproliferative disorder caused by specific mutations in the hematopoietic stem cell.  Essential thrombocythemia manifests as a very high platelet count, which predisposes patients to abnormal clotting.  The mainstay of treatment is reduction of the platelet count using hydroxyurea, anagrelide, or interferon. Pegasys is an alternate formulation of interferon that has less toxicity.  The current medical evidence shows that it can reduce the platelet counts of patients with essential thrombocythemia.  There is sufficient support for the requested medication in this patients case, and it is a standard agent used in myeloproliferative disorders.  All told, the requested Pegasys is medically indicated for the treatment of this patient.  Final Result: The reviewer determined that 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 medical oncology 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 41-year-old male enrollee has requested a Medtronic MiniMed continuous glucose monitoring device for the treatment of his type I diabetes. Findings:  The physician reviewer found that the use of the proposed CGMS is appropriate in this case because despite the patients diligence in attempting to control his sugar with an insulin pump, he has thus far been unsuccessful. A New England Journal of Medicine article states there is beneficial effect from CGMS as evidenced in the study in patients with type I diabetes mellitus with the primary outcome being a change in the glycated hemoglobin at 26 weeks. The article concluded, Continuous glucose monitoring can be associated with improved glycemic control in adults with type 1 diabetes. Based on the clinical evidence provided, the patient is appropriate candidate for the CGMS device and is likely to benefit from its use.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for panitumumab (Vectibix) 6 mg/kg 390 intravenous every two weeks in combination with dabrafenib (Tafinlar) 150 mg PO two per day plus trametinib (Mekinist) 2 mg PO once a day for treatment of the enrollees colon cancer. Findings:  The physician reviewer found that refractory or relapsed cancer who have exhausted standard treatments are usually considered for clinical trials. Recently, it has become important to identify mutations that may be amenable to targeted therapy. Researchers performed a study of 86 patients where the progression-free survival on a regimen selected by molecular profiling was compared to the progression-free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. Trametinib is an inhibitor of MEK kinases approved for use in metastatic melanoma with mutant BRAF. The MEK kinases are within the same pathway as RAS and BRAF. Thus, it is mechanistically appealing to apply trametinib to tumors with constitutive RAS signaling. Other researchers evaluated dabrafenib combined with trametinib in patients with BRAF mutant metastatic colorectal cancer. The authors noted one complete response and some partial responses with trametinib and dabrafenib in BRAF mutant colon cancer patients. In this patients case, the results from molecular profiling offers a rational selection of the next regimen. Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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 parent of a two-year-old male enrollee has requested speech and language therapy for treatment of the enrollees delayed speech. Findings:  The physician reviewer found that the patients developmental speech delays cannot be attributed to a medical diagnosis. The patients hearing is within normal limits and milestones were achieved at age appropriate levels. The patient has no documented laryngeal deficits or craniofacial abnormalities. According to the available medical literature, speech delay in this age group is often benign and improves with age. The fact that the patients brother was also delayed in speech and his family speaks Spanish and English in the home are positive indicators for this patients condition to be a delay rather than a deficit. The issue of pragmatic deficits may warrant further testing and may require the provider to rule out autism. Given the mild nature of the patients delay, the requested speech therapy is not medically indicated for this patient at this time.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:The parent of a one-year-old male enrollee has requested authorization and coverage for an OtoSCOPE hearing loss genetic testing panel. The International Pediatric Otolaryngology Group (IPOG) consensus recommendations for the workup of hearing loss in pediatric patients reported that in the setting of SNHL, comprehensive genetic testing is an appropriate next step following physical examination and audiogram. Researchers found in a study of 1,119 patients that comprehensive clinical genetic testing with targeted genomic enrichment and massively parallel sequencing identified an underlying genetic cause for hearing loss in 39% of patients. Researchers identified an overall diagnostic rate of 41% with hearing loss genetic panels using massively parallel sequencing. The medical literature noted that comprehensive genetic testing should form the cornerstone of a tiered approach to the clinical evaluation of patients with hearing loss. The OtoSCOPE panel includes testing for markers of Pendred syndrome. In this case, based on available clinical documentation and peer-reviewed evidence, an OtoSCOPE genetic testing panel is likely to be more beneficial in identifying the underlying etiology of the patients congenital SNHL, as compared to other available standard interventions. Therefore, an OtoSCOPE hearing loss genetic testing panel is likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested service is 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 service is likely to be 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 otolaryngology 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 40-year-old female enrollee has requested authorization and coverage for Mavyret 100-40 mg, three tablets daily, for eight weeks. 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret three tablets daily for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (case study). The ENDURANCE-1 trial showed that only eight weeks of treatment is needed (case study). The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (case study). For these reasons, the requested Mavyret 100-40 mg, three tablets daily, for eight weeks is supported as medically necessary for treatment of this patients hepatitis C virus infection. 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 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: Experimental/Investigational
Decision: Upheld

The parent of a 3-year-11-month-old male enrollee has requested occupational therapy visits using sensory integration techniques for treatment of the enrollees global developmental delays. Findings:  Two physician reviewers found that upon review of the occupational therapy notes provided, the daily reports do not address the functional goals as outlined in the quarterly progress reports. Rather, the daily treatments are based on sensory integration theory alone, and the functional goals are not addressed.  There is a lack of prospective studies that have shown that sensory integration therapy alone is better than standard occupational therapy. The review by Leong and Carter demonstrated a lack of evidence behind the use of sensory integration therapy for children with developmental delays. All told, the requested services are not likely to be the more efficacious for this patient than standard modalities.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old female enrollee has requested for speech therapy provided for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that Gallagher and Chiat found that, Studies of children with language impairment have reported emotional and behavioral problems in 50-75% of that population. In addition, various authors describe children with delayed speech development as being at high risk for other cognitive, social-emotional, and school-related problems. As such, language development is one of the most significant processes of early childhood development. With regard to diagnosis, language disorders are identified when a patient has difficulty with expressive language, receptive language, or pragmatic language. Speech disorders are identified when a patients voice, fluency, or articulation call attention to the speaker because his or her speech is sufficiently different from the norm. Speech and language development should be consistent with a patients overall development and can be tracked using typical milestone markers. Speech therapy is the standard of care for patients with speech delay and therefore is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old female enrollee has requested Taclonex for the treatment of her psoriasis. Findings:  The physician reviewer found that this topical medication (Taclonex) has already demonstrated efficacy where others have failed, its coverage is reasonable and medically necessary. Taclonex is a safer option for this patient relative to systemic therapies which would be warranted with the extent of her psoriasis.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 42-year-old female with weakness and fatigue of undiagnosed origin. The patient is currently independent with an exercise program at the local pool. She is requesting authorization and coverage for aquatic therapy. The Health Plan has denied this request indicating the requested therapy is not medically necessary.The Health Plans denial should be upheld. The patient has weakness and fatigue and wishes to receive aqua therapy. Aqua therapy under the direct supervision of a therapist is not medically necessary for this patient.  The submitted evidence indicates the patient is currently independent with an exercise program at a local pool. Since the patient is able to participate in an independent pool program, the requested therapy would be for purposes of maintenance and therefore, is not medically warranted. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Sprint peripheral nerve stimulation (PNS)  system. In an evaluation on the efficacy of PNS of the medial branch nerves to treat chronic axial back pain after failed attempts to manage the symptoms with a radiofrequency ablation, researchers noted that at two months after PNS, a majority of participants reported clinically significant reductions of 50% or greater in average pain intensity along with clinically significant improvements in functional outcomes. The authors reported that five months after PNS, 93% of the participants reported clinically meaningful improvement in one or more outcome measures, and a majority experienced clinically meaningful improvements in pain intensity, disability, and pain interference. In a study on the efficacy of PNS to treat chronic low back pain, one study reported no serious or unanticipated adverse events in patients twelve months after PNS treatment. In this case, visit notes report that the patient has chronic low back pain and has tried a wide spectrum of standard treatments, including lumbar facet joint injections, nonsteroidal anti-inflammatory drugs (NSAIDs), opioid analgesics, transcutaneous electrical nerve stimulation (TENS) unit, and physical therapy. In this clinical setting, current medical literature supports the superiority of the requested service for sustained relief over standard conservative treatment. Therefore, a Sprint PNS system is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Sprint peripheral nerve stimulation (PNS)  system is 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 service is likely to be 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 anesthesiology with sub-specialty certification in pain medicine 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:   An enrollee has requested a consultation with a fertility specialist for treatment of her possible egg retrieval and use of a surrogate.  The physician reviewer found that according to Kuohung and Hornstein, Age is an important factor affecting a womans fertility. The decrease in fecundability with aging is likely due to a decline in both the quantity and quality of the oocytes....The likelihood of a fertilized egg implanting is related to the age of the woman who produced the egg. Thus, the percentage of transfers resulting in live births for cycles using embryos from women's own eggs declines as women get older. Moreover, Chung and Paulson state Many women who delay childbearing may face infertility by the time they are ready to become pregnant. Women of advancing reproductive age who wish to delay childbearing may consider methods of fertility preservation, including embryo and oocyte cryopreservation....Success of mature oocyte cryopreservation has improved dramatically over the past decade, and it is no longer considered experimental by the American Society for Reproductive Medicine (ASRM) or American College of Obstetricians and Gynecologists (ACOG). For women who do not have a participating male partner and are not interested in using donor sperm, oocyte cryopreservation is generally the preferred option. In this case, the patient concerned about her potential for fertility and requests expert information about her options. She is not in a partnered relationship, so trying currently for a pregnancy is not an option. Her gynecologist has referred her to a fertility specialist so she can explore the option of egg freezing. The patient is also concerned about whether she can carry a pregnancy and wants to discuss the option of surrogacy. This patient is at a crucial time for cryopreservation, if she chooses to pursue it and she cannot decide about her future options without input from a reproductive technologist. Therefore, the patients request for a consultation with a fertility specialist is medically necessary. 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 obstetrics and gynecology 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: A patient has requested authorization and coverage for Otezla 30 mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients psoriasis vulgaris. The submitted documentation supports the medical necessity of the requested medication. The patient has a history of chronic plaque psoriasis. Per the records, the patient has been stable on Otezla for the past three years. The patient has tried and failed treatment with acitretin and topical steroids. It is unreasonable to require that the patient take two immunosuppressive medications prior to approving the current effective therapy, which is U.S. Food and Drug Administration approved for the patients condition. The medical evidence supports the requested medication in this clinical setting. Therefore, Otezla 30 mg 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 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.