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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Saizen 8.8 mg vial for treatment of the enrollees growth hormone deficiency. Findings:  The physician reviewer found that the request for Saizen 8.8 mg vial is medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient has had a good response to GH therapy and has had no adverse reactions to Saizen. The patient experienced an allergic reaction to Nutropin, so brand name Saizen is medically necessary for treatment of the patients GH deficiency. The patients epiphyses remain open so continued treatment until epiphyseal fusion is clinically indicated. As such, the request for Saizen 8.8 mg vial has been established as 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 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: The patient has requested authorization and coverage for Entyvio 300 mg. Entyvio has been demonstrated to be safe and effective for the treatment of patients with ulcerative colitis (Rubin, et al.). One study reported that Entyvio was more effective than Humira at 52 weeks, and safer as well (Sands, et al.). The American Gastroenterological Association (AGA) guidelines state that, patients, particularly those with less severe disease, who place higher value on the potential safety of medications, and a lower value on the relative efficacy of medications, may reasonably choose vedolizumab (Feuerstein, et al.). The AGA guidelines support treatment with Entyvio for induction of remission in ulcerative colitis (Feuerstein, et al.). Entyvio has shown efficacy for the treatment of ulcerative colitis in high-quality studies, including randomized controlled trials (Mosli, et al.; Lin, et al.). The records provided for review document that this patient has ulcerative colitis that failed to improve with Uceris and mesalamine. The patients symptoms have been adequately managed with Entyvio. The provider has recommended continued treatment with Entyvio. Given this patients positive response to Entyvio, discontinuation or change to another agent may result in uncontrolled ulcerative colitis and disease complications. For these reasons, the requested Entyvio 300 mg 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 internal medicine with subspecialty 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 reimbursement for the Zoll LifeVest (K0606). The Health Plan has denied this request indicating that the equipment at issue was not medically necessary for treatment of the enrollee who has a history of congestive heart failure. Findings: Current medical literature does not support the equipment at issue in this clinical setting. At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed or require explantation. Based on the records provided, the patient had a newly recognized cardiomyopathy with an ejection fraction of 20-25% that subsequently improved on repeat echocardiograms. In this circumstance, there was recovery of left ventricular function over time with medical therapy above the level where a defibrillator is recommended and there was no documented indication for placement of a defibrillator such as sustained or inducible ventricular tachycardia, unexplained syncope or aborted sudden cardiac arrest. A prophylactic defibrillator, wearable or implantable, during the time period in question has not been demonstrated to improve outcome. Moreover, studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups. In addition, more recent retrospective trials in patients with newly diagnosed nonischemic cardiomyopathy have not demonstrated benefit with prophylactic wearable defibrillators.  In addition, preliminary results of the Vest Prevention of Early Sudden Death Trial (NCT01446965) were reported during the American College of Cardiology national meeting and the outcome failed to show a reduction in sudden cardiac death in the group treated with external defibrillators. As such, a Zoll LifeVest (K0606) has not been demonstrated by scientific literature as medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the equipment at issue was 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 internal medicine with sub-specialty certification in cardiovascular disease 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: The patient has requested authorization and coverage for Euflexxa injections in the right knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patients treatment options are limited. The patient has tried and failed non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, and arthroscopic surgery with the alternative being a total knee arthroplasty. His osteoarthritis is mild and does not require a total knee arthroplasty. As such, the requested Euflexxa injections of the right knee are 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 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: Overturned

The patient is a 41-year-old female with a history of past addictions to benzodiazepines and opiates. She apparently was subsequently prescribed narcotics for pain associated with a diagnosis of multiple sclerosis and became addicted to Vicodin. Her physician prescribed Suboxone to gradually withdraw the patient from Vicodin. It appears the patient left his care prior to completion of the planned treatment. A urine drug screen in October 2005 was clear. The Health Plan indicates Suboxone was not medically necessary for treatment of the patients medical condition and therefore has denied reimbursement for the drug.The submitted records indicate Suboxone was prescribed to gradually wean the patient off of opiates. Apparently the patient continued to get prescriptions for benzodiazepines but no opiates during the Suboxone taper. Based on the records provided, it appears the patient was compliant with the prescribed treatment as Suboxone was last filled in October 2005. A hydroxyzine prescription was filled in November 2005. No opiate prescription was filled during treatment with Suboxone. As such, the medication at issue was medically appropriate and indicated for treatment of the patients opiate dependence. Accordingly, 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 for breast tomosynthesis for evaluation of the enrollees risk for breast cancer.   Findings:  The physician reviewer sfound that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. Final Result: All three reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.   Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in diagnostic radiology 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

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Otezla 30 mg for treatment of the enrollees moderate psoriasis. Findings:  The physician reviewer found that the patient presents with chronic plaque psoriasis. She has tried and failed therapy with topical steroids. She has been treated with Otezla with good effect. However, there is no documentation of the patient having tried and failed any of the first-line systemic treatments, including methotrexate, cyclosporine, Humira or Enbrel. In addition, there is no documented contraindication to the use of these agents which have been used successfully and safely for years. As there are other preferred medical therapies available, the requested Otezla 30 mg is not medically necessary for treatment of this patients plaque psoriasis. 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 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

A 33-year-old female enrollee requested authorization and coverage of eight Imitrex injections per month. The Health Plan denied the request indicating that the medication is not medically necessary for treatment of the enrollees migraine headaches.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that 6-7 Imitrex injections per month are medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a four-year-old male enrollee has requested authorization and coverage for 40 hours per week of applied behavioral analysis (ABA) therapy with eight hours per week of supervision, and two hours per week of parent training for treatment of the enrollees autism spectrum disorder.   Findings:  The physician reviewer found that The request for 40 hours per week of ABA therapy with eight hours per week of supervision, and two hours per week of parent training is not medically necessary for the treatment of the patients medical condition. There is a lack of documentation provided to support the requested frequency of ABA hours in this clinical setting. The patient presents with a history of autism, mental delay, anxiety and a sensory processing disorder.  The patient is likely to benefit from an early intervention pre-kindergarten program in conjunction with ABA therapy. In addition, the Health Plans authorization of 25 hours per week of direct ABA service with a paraprofessional weekly, with four hours of supervision, and one hour of parent training is medically necessary and appropriate in this clinical setting. Final Result: The reviewer determined that the requested services 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 pediatrics and neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 13-year-old male with a diagnosis of autism who has been receiving speech therapy three times a week for one-hour sessions since January 1999. He has made progress toward communication, but continues to have difficulties with pragmatics and social communication. Additionally, auditory comprehension and behavior continues to be an issue. The patients parent has requested coverage for continued speech therapy. The Health Plan has denied the request on the basis the requested therapy is not medically necessary for treatment of the patients condition.Review of the relevant medical literature reveals no support for individual therapy to treat the remaining areas of deficiencies in the patients speech. The patient has difficulty with pragmatics, social communication, and auditory processing, all of which are educationally based deficiencies rather than medical issues. As such, standard of care is to manage the patients condition through other means than individual speech therapy. 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: Medical Necessity
Decision: Upheld

The patient is a 43-year-old male who is status post lumbar surgery for decompression and fusion. His orthopedist prescribed a thoracolumbosacral orthosis (TLSO) to assist with his postoperative rehabilitation. The patient has requested reimbursement for the cost of the device. The Health Plan denied his request based upon a determination that the TLSO was not medically necessary.The efficacy of a TLSO following lumbar decompression fusion surgery has not been established. No prospective study has been conducted to support its general use. There is no evidence that the use of a TLSO was likely to result in an improved clinical outcome for this patient. Therefore, I have determined the device at issue was not medically necessary for the patients postoperative rehabilitation. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old female enrollee requested authorization and coverage to undergo a laparoscopic revision of an ileorectal anastomotic stricture with a particular physician. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees partial bowel obstruction.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested for a custom knee brace for treatment of the enrollee, who is status post knee surgery. Findings:  The physician reviewer found that there is a lack of support in the peer-reviewed medical literature for the efficacy of bracing after anterior cruciate ligament reconstruction. As noted by Wright and Fetzer, there is a lack of evidence demonstrating that pain, range of motion, graft stability or protection from subsequent injury were affected by brace use. No long-term differences in clinical outcome were identified in patients who wore postoperative braces as compared to those who did not. There have been some reports of decreased pain with brace use in the early postoperative period, but no differences in function or laxity at follow-up, as noted by Brandsson and colleagues.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 32-year-old female. She has a history of alcohol abuse since the age of 19. Until recently, she reportedly had been drinking four beers and four shots of whiskey each day.  She mixed alcohol with Soma, taking 90 pills in a two-week period. The patient also abused Vicodin and over-the-counter cough syrup. She entered inpatient hospitalization for detoxification in March 2004, and was safe for a lower level of care in April 2004. She then entered a partial hospitalization program, for which she is requesting reimbursement. The Health Plan authorized 1 day of inpatient detoxification, 5 days of inpatient rehabilitation, and 17 days of intensive outpatient therapy.At issue is whether the services at issue were medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. The patient was not diagnosed with a comorbid psychiatric disorder, and was not suicidal or psychotic during the period at issue. The records provided fail to demonstrate that partial hospitalization services were warranted. The care authorized by the Health Plan was medically reasonable and appropriate for treatment of the patients behavioral health problems. Therefore, I have determined that the services at issue were 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 a consultation with a plastic surgeon for treatment of her gender dysphoria. Findings: The physician reviewer found that review of the submitted documentation reveals that the patient is prepared for the next step of a surgical evaluation.  The patient has had previous gender reassignment surgery, which demonstrates she is an appropriate candidate for gender transition services. Consultation for further surgical intervention is the next appropriate step in the treatment of the patients gender dysphoria. Therefore, the requested plastic surgery consultation is medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested service 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 plastic 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 38-year-old female enrollee has requested transcranial magnetic stimulation for treatment of her behavioral health issues. Findings:  Three physician reviewers found that there are several factors in this case that make TMS inappropriate for this patient including the fact that her mood and anxiety have been documented to be good and she is in fact being tapered off of her medications. Further, her provider noted that a majority of her symptoms appear secondary to her relationship, which is not likely to be alleviated with TMS. In addition, the available medical publications, including those referenced above, support that this patients current diagnoses of panic disorder with agoraphobia and generalized anxiety disorder are not recognized diagnoses that have support for treatment with TMS. Thus, while there is some data to support the use of TMS for depression, it is insufficient to support the use of TMS in this patient over conventional treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for proton radiation therapy for treatment of the enrollees anal cancer. Findings:  The physician reviewer found that based on review of available data, the services at issue were not medically necessary for the treatment of the patients anal carcinoma. There is very limited clinical studies comparing proton therapy to photon intensity modulated radiation therapy (IMRT) for anal cancer. Additionally, there are a few studies on proton therapy for rectal cancer, but rectal cancer is not the same entity as anal cancer as the treatment approach and radiation fields differ significantly. One existing clinical data on anal cancer is a Japanese case study where a single patient with distant metastases had their primary anal cancer site treated with protons. Per researchers, the authors note the following, anorectal  cancer  offers  an  open  arena  to  explore  clinical  outcomes  and  toxicities  to  back  up  dosimetric superiority data. Based on the available data, proton radiation therapy was not medically necessary for the treatment of this patients anal cancer. 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 radiation 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.