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

The patient is a 56-year-old male who has a history of ulcerative colitis - in remission, cirrhosis secondary to primary sclerosing cholangitis, non-Hodgkins lymphoma - in remission and multiple sclerosis. He has been recommended for a liver transplant. He reports marked fatigue and usually remains at home in bed. The patients attending physician recommends Provigil for treatment of the patients marked fatigue. The patient also experiences erectile dysfunctions for which he has been advised to take Viagra.At issue in this case is whether Provigil is medically necessary for treatment of the patients medical condition.Provigil is appropriate for treatment of fatigue secondary to certain chronic medical conditions including fibromyalgia, chronic fatigue syndrome, narcolepsy and multiple sclerosis. The patient has a serious liver condition and multiple sclerosis resulting in marked fatigue. Based upon the information provided, there are no contraindications to Provigil. In light of the patients diagnoses and his debilitating fatigue, Provigil is medically reasonable and appropriate in this setting. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for percutaneous tibial nerve stimulation (PTNS) (procedure code 64566).Findings:  Two of the three physician reviewers found that the current medical evidence supports the services at issue in this clinical setting. PTNS is an appropriate treatment for overactive bladder. The treatment is minimally invasive, repeatable and can be adjusted in its application to treat patients according to symptoms. It does not preclude the use of other forms of treatment. In more severe cases of overactive bladder syndrome, PTNS may need to be used in combination with overactive bladder medications in order to resolve symptoms. This patient experienced symptom relief with the use of PTNS. Therefore, PTNS was and is likely to be more effective than other treatment options. Final Result: The reviewers determined that the services at issue were and are 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 urology 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

The parent of a 13-year-old male enrollee has requested growth hormone therapy (Saizen, 8.8mg, 1.5 cartridge) for treatment of the enrollees growth failure in the setting of an abnormal pituitary MRI.  Findings:  The physician reviewer found that although this patients height is more than two standard deviations below normal for age and sex, his adult predicted height based on one bone age assessment and height measurement falls within normal range for an adult male.  Although the provider argues that this patients growth velocity is abnormally low, the low growth velocity of 3.2 cm per year is based only on two measurements that are 3 12 months apart, and the duration of time between these two measurements is not long enough to declare the growth velocity to be abnormally low.  Pre-treatment growth velocity for at least a one-year time period should be documented prior to consideration of growth hormone therapy, particularly during the peripubertal period, when some children may normally have a slump in linear growth.The finding of a flattened pituitary gland on MRI does not, in and of itself, argue for growth hormone deficiency, particularly when biochemical testing shows normal results, there is no evidence of any other pituitary deficiencies, and there is no clear documentation of abnormal linear growth velocity over at least one year of time.  The fact that the patient experienced acceleration in growth after treatment with growth hormone therapy does not prove that he is growth hormone deficient. Without documentation of pre-treatment pubertal stage, it is possible that sex steroid secretion has contributed to the boost in his growth velocity coincident with administration of growth hormone therapy. Additionally, augmentation of growth may occur with growth hormone therapy even in children without bona fide growth hormone deficiency.  All told, the medical necessity of the requested growth hormone therapy has not been established by the submitted documentation.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested the combination treatment of bone replacement graft and guided tissue regeneration for the treatment of her medical condition. Findings:  The physician reviewer found that bone graft replacement on tooth numbers 25 and 30 was medically necessary, but guided tissue regeneration was not medically necessary. This is because the evidence submitted in this case does not support the medically necessity of both the bone grafting and guided tissue membrane placement. Although the medical literature does indicate that in certain situations both materials can work synergistically to improve the result of bone regeneration and reduce pocket depth where bone loss is marked, in this particular case the submitted documentation does not demonstrate that such a condition existed. Based on the information provided, using both procedures, was unnecessary because the bone loss and pocket depths did not appear extensive enough to require each. The pocket depths indicate that the patient, at most, had Class II/(early) Class III periodontal disease. In this situation, the patients bone loss would most likely have been minimal, or there possibly was an isolated vertical defect that might have benefited from bone grafting. There is no evidence that there was sufficient missing structure from the walls of bone supporting the teeth to require the additional use of guided tissue regeneration membrane.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, non-cirrhotic genotype 1 patients who have failed peg-interferon and ribavirin should be treated with Harvoni for 12 weeks. These guideline 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. For these reasons, the requested treatment with Harvoni is medically necessary for the treatment of this patients hepatitis C 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: Medical Necessity
Decision: Upheld

The patient is a 16-year-old male with left lower lobe and minimal right middle lobe bronchiectasis. The patient does not have cystic fibrosis. Review of the submitted records indicates daily chest physical therapy has not been used. A request has been made for the Vest Airway Clearance System (the Vest). The Health Plan has denied the request indicating that the Vest is not medically necessary based upon the information provided.The Vest is a high frequency chest wall device for chest physical therapy and has been available since 1988.  It has been studied most frequently in patients with cystic fibrosis where daily chest physical therapy is generally accepted treatment. There are no randomized, controlled, long-term clinically significant outcome clinical trials (where the end point is fewer hospitalizations for pulmonary infections or decrease in the progression of pulmonary disease) that document the safety and efficacy of the Vest in patients with bronchiectasis.  Furthermore, any patient with a recent pulmonary infection will have local bronchiectatic changes.  Chest physical therapy is the generally accepted treatment for clinically significant bronchiectasis and there is no documented superiority of the Vest over chest physical therapy except for convenience.    Based upon the information set forth above, I have determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene test related to prostate cancer, called Confirm MDx. Findings:  The physician reviewers found that there is a lack of medical literature that indicates the benefit of the services at issue in this clinical setting. The gold standard in the management of prostate cancer remains the identification of prostate cancer on a prostate biopsy to be followed by the appropriate treatment. ConfirmMDx has not been validated with prospective randomized clinical trials. There is a lack of evidence to show a difference in long term or short term outcomes, alteration of treatment approach, improvement in quality of life or an improvement in overall or progression free survival.  The risk of detecting cancer is not well defined in this test. Moreover, knowing the risk of detecting prostate cancer on repeat biopsy, as suggested by the ConfirmMDx test, would not preclude the provider from requesting a biopsy because this test has no impact on survival or management. In addition, the identification of risk (high versus low) grade disease, would not be beneficial since a tissue diagnosis is needed to confirm the diagnosis as well as render the histological behavior of the disease. For these reasons, ConfirmMDx performed was not likely to have been more effective than the available methods for the evaluation of this patients medical condition. Final Result: 2 of 3 reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical 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

A 23-year-old female enrollee has requested for a Nucleus Freedom Speech Processor for treatment of her bilateral hearing loss. Findings:  The physician reviewer found that the patients current ESPrit 3G processor is functioning well and there has been no change in the patients physical condition requiring a change in processor. Although there is an improvement in the patients performance with the Freedom processor, the changes are relatively small, and do not result in a dramatic difference in the patients functional status.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female requested authorization and coverage for a panniculectomy.  The enrollees health plan denied the 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 procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment center (RTC) services for treatment of his behavioral health conditions. Findings:  The physician reviewer found that the Level of Care Utilization System (LOCUS) criteria, are commonly used measure for determining appropriate levels of care. The patients risk of harm was moderate (score 3) since the patient denied suicidal ideation on admission, has a history of overdosing without clarity regarding his intention, excessive use of substances, and cutting himself. The patients functional status demonstrated moderate impairment (score 3) as he has a conflictual relationship with his parents, is unable to fulfill responsibilities, and he had an episode where he broke a chair and damaged property at his IOP. The patient demonstrates significant co-morbidity (score 3) with a co-existing alcohol use disorder, cannabis use disorder, borderline personality disorder, social anxiety disorder, body dysmorphic disorder, and major depressive disorder. The patient has a mildly stressful recovery environment (score 3) with interpersonal conflicts with his biological father, and supportive environment with his mother who is willing to participate in treatment and provide aid in times of need (score 2). The treatment history shows the patient has had an equivocal response to treatment (score 3) with one year of IOP treatment with partial recovery maintained for moderate periods of time with strong professional support and in structured settings. The patient has demonstrated limited engagement and recovery (score 3) with difficulty engaging in treatment. This provides a total score of 20, which is consistent with partial hospitalization program (PHP) level of care. Further, the patient stated that he did not want to be in an RTC and preferred to be in a lower level of care. It the standard of care to treat all patients in the least restrictive environment to effectively and adequately address their condition. Given these findings, the RTC services provided were not medically necessary for treatment of this patients behavioral health issues.Final Result: The reviewer determined that the services at issue were 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 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 28-year-old female enrollee requested authorization and coverage of gastric bypass and 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 a gastric bypass and duodenal switch are 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: Medical Necessity
Decision: Upheld

The patient is a 58-year-old male who has been treated for hypercholesterolemia for several years.  His provider states the patient was not able to tolerate dosages of Lipitor greater than 10 mg or the combination drug Vytorin.  In October 2005 the patients total cholesterol level was 154 mg/dL to 189 mg/dL and his LDL level was 97 mg/dL to 116 mg/dL. The patient reports that he began treatment with Zetia in October 2005.  The record does not include any cholesterol or LDL levels after October 2005.  The patients request for authorization of Zetia was denied based upon the Health Plans determination that it was not medically necessary to treat the enrollees hypercholesterolemia.The NCEP/ATP III guidelines recommend statin drugs as the standard therapy for managing high cholesterol in adults.  Non-standard therapies such as Zetia are indicated when statin therapy is not tolerated or LDL goals cannot be achieved with statin therapy alone.  Although the provider points out that Lipitor and Vytorin have been tried, there is no documentation of other statin drugs that have been tried and found ineffective or intolerable.  Additionally, the clinical indication for Zetia is not clear. Laboratory values from October 2005 demonstrate LDL levels that are near optimal, before Zetia was prescribed. Peer-reviewed studies have demonstrated that statin therapy reduces the risk of coronary artery disease (CAD).  Zetia alone has been shown to reduce LDL cholesterol, and Zetia in combination with a statin drug further reduces LDL cholesterol.  However, research outcome data has not yet demonstrated that the LDL reduction with Zetia is superior to statin therapy alone.  Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz (tofacitinib) tablets.Findings: Currently, there are no treatments approved by the U.S. Food and Drug Administration (FDA) for treatment of GA, and so any use of a drug or therapy would be considered off-label. Xeljanz is a highly active advanced small molecule that is currently undergoing an open-label trial for FDA-approval for treatment of GA. A study found, Topical Janus kinase inhibitors may be beneficial in patients with cutaneous granulomatous disorders with limited involvement. In another study, Tofacitinib resulted in dramatic improvement in patients with cutaneous sarcoidosis and GA. In this case, the patient has tried and failed alternatives, including steroids, phototherapy, and multiple disease modifying antirheumatic drugs (DMARDs). Additionally, there is support in the literature for the use of tofacitinib in the treatment of GA. Therefore, the requested Xeljanz (tofacitinib) tablets are medically necessary for treatment of the patients medical condition.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: Medical Necessity
Decision: Overturned

The parent of a one-year-old female enrollee has requested speech therapy for treatment of the enrollees delays in receptive and expressive language and speech skills.  Findings:  The physician reviewer found that speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success. Identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Preschool-aged children with speech and language delay may be at increased risk for learning disabilities once they reach school age. Speech and language delay must be taken seriously in young children because the long-term consequences may be substantial. According to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  The authors concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  This patient has moderate speech and language delay that adversely impacts her ability to communicate with those around her. If not addressed, her communication delays may adversely impact interactions with peers and caregivers. Studies have shown that speech and language therapy can result in significant improvement in this clinical situation. All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 43-year-old male enrollee requested injection of periurethral bulking agents (CPT code 51715) for medical treatment of his urine leakage.  Findings:  Three physician reviewers found that according to the American Urological Association (AUA) guidelines, periurethral injection of bulking agents are considered a second-line treatment option after failure of conservative measures for the management of stress urinary incontinence. In this case, the medical records provided for review do not show that the patient has tried and failed first-line treatment such as exercises or medication. Therefore the requested services are not likely to be more beneficial for treatment than standard treatment options in this clinical setting.