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

The mother of a five-year-old male enrollee requested authorization and coverage of continued speech therapy.  The Health Plan denied the request indicating that the requested therapy is not medically necessary for the treatment of the enrollees speech disorder.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has chronic pain related to a motor vehicle accident. Records noted that the patient  was prescribed tizanidine and Tylenol #3. The Health Plan has denied this request and reported that the requested medications are not medically necessary for the treatment of this patient. The submitted documentation fails to demonstrate the medical necessity of the requested medications. The stepwise World Health Organization (WHO) ladder for pain relief is considered a reasonable approach to pain control in the palliative setting. In this patients case, not all non-opioid treatment options have been utilized. There is no mention of the completion of behavior therapy documented, despite significant research supporting its use. Furthermore, no objective treatment goals for pain and function are noted for the requested medications. The Centers for Disease Control and Prevention states when opioids are started, clinicians should prescribe the lowest effective dosage. Moreover, the medical evidence supports muscle relaxants only for short-term use. Not all non-opioid medications classes have been optimized or tried. Therefore, Tylenol #3 and tizanidine are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology, sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested growth hormone, Nutropin AQ, for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication. According to the documentation submitted for review, the patients height is not more than 2 standard deviations below the mean for age and gender, and he has a normal growth velocity, normal pre-treatment IGF-1 level, and no known morphological abnormality of his pituitary gland. His bone age is delayed, but not due to GH deficiency. Based on the patients pre-treatment bone, the estimated final adult height is a normal adult height prediction and appropriate for the patients genetic potential. The patients peak GH response on provocative GH testing is borderline low, but such testing has poor sensitivity and specificity for a diagnosis of GH deficiency in the setting of normal growth velocity. Based on the medical literature cited above and the documentation submitted for review, the request for Nutropin AQ is not medically necessary for treatment of the patients medical condition. Final Result: The reviewers determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  The physician reviewer is board certified 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 Harvoni for treatment of her hepatitis C virus (HCV).  Findings: The physician reviewer found that the medical necessity of HCV eradication as per American Association for the Study of Liver Diseases/Infectious Diseases Society of America (AASLD/IDSA) recommendations exists irrespective of fibrosis score. AASLD/IDSA guidelines, underscore this position with the following statement: Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months).  In this patients case, her medical records support the medical necessity of Harvoni to treat her hepatitis C virus. Consistent with current AASLD/IDSA guidelines, Harvoni is clinically appropriate and is likely to be efficacious for treatment of this patients condition. Thus, the medical necessity of the requested Harvoni has been established. Final Result: The reviewer determined that the requested medication is necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The physician 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

An enrollee has requested reimbursement for the Cartiva implant procedure. The records provided for review document painful left-sided hallux rigidus and hallux valgus. From a surgical perspective, first metatarsophalangeal joint arthrodesis or first metatarsophalangeal joint metallic implant remain the longstanding surgical standards of care for hallux rigidus. Numerous studies have demonstrated that well-selected patients can benefit with first metatarsophalangeal joint arthrodesis and are able to continue with vigorous physical activity. Metallic implants for the base of the proximal phalanx and the head of the first metatarsal have been shown to be safe and effective for the treatment of painful hallux rigidus. The Cartiva implant is a novel first metatarsophalangeal joint implant. Studies show that this implant carries its own risks and complications, and has not been demonstrated to be more safe or effective than first metatarsophalangeal joint arthrodesis or a first metatarsophalangeal joint metallic implant. All told, the Cartiva implant procedure was 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 services at issue were 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 podiatry 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 ten-year-old female enrollee has requested Vyvanse for the treatment of her attention deficit/hyperactivity disorder (ADHD). Findings:  The physician reviewer found that the patients diagnosis (ADHD) is not contested, nor is her need for treatment. A review of the records provided indicates the patient was given Concerta (methylphenidate class). A statement made by the treating physician indicates that she may not have tolerated this particular drug. However, I can find no record that she was treated with a drug in the amphetamine class. The Health Plan requires that the non-formulary compound (Vyvanse) be provided only after formulary drugs (compounds in both the amphetamine and the methylphenidate classes) are found to be unsatisfactory.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for peripheral bone density testing for possible osteoporosis.  Findings:  The physician reviewer found that There is a lack of support for the superior efficacy of the services at issue in this clinical setting. While the heel bone density screening test may be good at predicting fracture risk and is a reasonable test when trying to assess the patients risk factors for low bone mineral density (BMD), this test is not likely to be more beneficial than the available standard methods of assessing BMD risk. The medical literature show evidence that dual-energy x-ray absorptiometry (DXA, DEXA) scan of the hip yields better results when assessing for future risk fracture. As such, the peripheral bone density testing was not likely to have been more efficacious when compared to other standard modalities of evaluating this patients medical condition. Final Result: All three 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 patient is a 54-year-old female and has severe left leg and left torso lymphedema as a consequence of a pelvic lymph node dissection for advanced ovarian cancer.  Lymphedema secondary to extensive lymph node dissections for cancer tend to be the most severe cases of lymphedema.  There is documentation that the patient has had an adequate trial of other standard therapies including include wraps, compression stockings and garments, and manual lymph drainage with overall poor response. At issue is whether the Flexitouch Lymphedema System is medically necessary for treatment of the patients condition.The submitted clinical information indicates the patient has failed an adequate trial of conservative therapies.  There is extensive documentation of her prior therapies.  It might be expected that these therapies would not be successful, given the proximal nature of her lymphedema onto her trunk.  It is very difficult to apply compression to these areas.  The Reid Sleeve suggested by the Health Plan is essentially another form of static compression, which would not have any significant advantage over the previously tried wraps and compression garments. The FlexiTouch Lymphedema System has the advantage of being a dynamic pumping system that provides pumping and compression to all areas affected by the lymphedema including the proximal thigh, groin, and trunk.  It is generally accepted that lymphedema pumps are indicated when other therapies have failed. Therefore, I have determined the requested device is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old male enrollee has requested four months of treatment at the residential treatment level of care for treatment of the enrollees bipolar disorder, attention deficit/hyperactivity disorder and polysubstance dependence.  Findings:  The physician reviewer found that the records indicate that his suicide attempts were impulsive which makes them hard to predict. The patient has a history of gang involvement and has remained highly impulsive. Whether a four-month stay at a residential treatment level of care is medically necessary will depend on the patients future clinical status and response to treatment. At this point in time, the documentation provided does not support the medical necessity of a four-month admission. The patients progress will need to be continually monitored to determine the effectiveness and appropriateness of 24-hour supervised treatment. With regard to the frequency that concurrent review should be performed by the Health Plan, weekly evaluations are consistent with the standard of care in the psychiatric community and are appropriate for a patient being treated at this level of care.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 54-year-old female with multiple sclerosis (MS).  According to the record, she can walk with a cane for limited distances.  The patient states she has fatigue after walking short distances, and has decreased upper body strength.  The record did not include an objective assessment of the patients strength, range of motion, and mobility skills. The patient has requested authorization for a power-operated vehicle (POV). Her request was denied by the Health Plan based upon a determination that the equipment is not medically necessary.The records provided are not supportive of the patients need for a POV. Although the patient indicates she cannot operate a standard wheelchair, there is no specific evaluation of the patients mobility and no indication of a need for a POV within her home. The information provided indicates the patient can still walk a block with a cane. Also, the records indicate the patient walks with a cane most of the time. Therefore, I have determined the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old female enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the patient still required specialty care, but after months of residential treatment, a less restrictive therapeutic setting addressing her lingering academic and social struggles would have been safe, appropriate and consistent with good medical practice. The patient needed to transition to the outpatient setting and the holiday pass to another state was suggestive that the setting was no longer medically necessary for her condition. Considering the case in its entirety, cast upon current practice standards and relevant peer-reviewed literature, it was medically necessary for the patient to have been treated at the residential level of care.  However, it was not medically necessary for the patient to have been treated in the residential setting, thus continued residential treatment center level of care was no longer medically necessary and transition to a less restrictive setting would have been appropriate.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 53-year-old female with diagnoses of asthma, allergic rhinitis, gastroesophageal reflux disease (GERD), prolactinoma, and hypercholesterolemia. An upper GI study in 2002 revealed a hiatal hernia and esophageal reflux. The patient was first diagnosed with asthma three years ago by her treating provider who is a pulmonologist and allergist. A spirometry performed on 3/8/04 was interpreted as normal A chest radiograph dated 1/24/05 was interpreted as normal. Her current medical regimen includes Advair, Singulair, albuterol, Nasonex, and Prevacid. The patient also receives weekly injections for her immunotherapy. The Health Plan has determined it is not medically necessary for the patient to receive her weekly injections from a pulmonologist and has referred the patient to an allergist. The patient was evaluated by an allergist who agreed with the above treatment plan and noted the patients asthma was well under control. The purpose of this review is to determine whether a referral to a pulmonologist is necessary for management of the patients asthma.Based upon current NAEPP guidelines, the patients asthma appears to be well controlled. The patients immunotherapy injections were previously managed by a pulmonologist and are now managed by an allergist. Based upon the patients most recent chest x-ray and spirometry, the Health Plan does not believe the patient requires a pulmonologist. The information submitted does not demonstrate any radiographic abnormalities such as lung obstruction, hypoxemia, etc., which would require the management of a pulmonologist. Furthermore, the patients immunotherapy can be safely and effectively managed by an allergist.Based upon the information set forth above, I have determined the requested referral is not medically necessary for treatment of the patients medical condition. Therefore, I have determined the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of the enrollees hepatitis C.  Findings: The physician reviewer found that According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, 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, and advanced fibrosis is not required for treatment.  Per the guidelines, treatment-naive, genotype 1 patients should be treated with Harvoni.  Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials.  For these reasons, the requested treatment with Harvoni for eight weeks is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment center (RTC) services and partial hospitalization program (PHP) treatment services for treatment of her behavioral health condition.  Findings:  The physician reviewer found that the services at issue were not medically necessary for treatment of the patients medical condition. In this case, the patient did not meet criteria for RTC services and she did not meet criteria for PHP services. Specifically, there is a lack of evidence submitted for review demonstrating that the patient needed the required structure of residential or PHP, respectively, to motivate her to make progress, or to prevent her from acting on her behavioral health condition. There is also a lack of evidence that she was preoccupied with disordered thoughts about her behavioral health condition in excess of several hours daily. The documentation demonstrates that she consistently appeared well motivated and cooperative with her treatment, and even expressed the desire to be at the intensive outpatient program level of care while she was being treated at the PHP. In sum, the clinical documentation submitted for review has not established the medical necessity for the services at issue.  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 with sub-specialty certification in child and adolescent 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 29-year-old male enrollee has requested use of Dynasplints (one adjustable knee extension and one flexion splint) for the treatment of the enrollees fracture. Findings:  Two physician reviewers found that this patient had application of a Dynasplint following his original surgery. Based on the scientific evidence available to date, the use of Dynasplint therapy in this setting would not have been predicted to result in substantial improvement. In fact, it was noted that this patient did not appear to make substantial progress in flexion following the original measurements that were obtained. He made modest gains in extension. Therefore, this patient did not see substantial improvement in flexion or extension. Thus, use of a Dynasplint was not of significant value during these dates of service. This patient used a Dynasplint again following another surgical procedure. There did not appear to be reasonable support for continued utilization of a Dynasplint, as the records did not document any significant further improvement beyond that which was originally seen in the first month or two following the procedure. Therefore, use of a Dynasplint after the enrollee's second surgery did not result in a superior outcome for this patient.