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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of the enrollees hepatitis C. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication regimen.  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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage.  Per the guidelines, non-cirrhotic, treatment-naive, genotype 1 patients should be treated with Harvoni for 12 weeks or Zepatier for 12 weeks. The guidelines recommend either Harvoni or Zepatier as first-line therapy.  Of note, there is a need for NS5A resistance testing prior to Zepatier in genotype 1a.  The guidelines cite data showing reduced survival with delayed treatment.  Although treatment of hepatitis C is needed, the requested medication regimen, Harvoni for eight weeks, is not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen, without trial and failure of Zepatier, 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 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 44-year-old male with a history of possible onychomycosis. He reports pain and that he has twice had a toenail removed. He further reports he has been taking Lamisil and that his condition has improved. However, there is no evidence the patient has had a fungal culture confirming a fungal infection. Because of a lack of information, the Health Plan has denied authorization for Lamisil.In order to determine whether Lamisil is necessary there must be laboratory documentation confirming fungal infection and clinical documentation demonstrating pain/functional impairment. Such information is lacking in this matter. Therefore, Lamisil cannot be considered medically necessary at this time. If the patients provider provides clinical and laboratory documentation confirming fungal infection and pain/functional impairment, the Health Plans denial should be reconsidered. However, at this time Lamisil is not medically necessary. Therefore, I have determined the Health Plans denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 25-year-old male enrollee requested authorization and coverage of an MRI of the lumbar spine. The Health Plan denied the request indicating that the requested MRI is not medically necessary for evaluation of the enrollees meralgia paresthetica.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested MRI is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old male enrollee has requested Enbrel 50mg/ml (twice per week) for treatment of his palmar/plantar psoriasis.  Findings:  The physician reviewer found that in this patients case, his prior treatment for recalcitrant palmar/plantar psoriasis has included Enbrel, acitretin, and UVA phototherapy with psoralen (PUVA).  He continues to have painful flares of his psoriasis.  The patients provider reported that the patient experienced flares when he was tapered to once weekly dosing of Enbrel 50mg/ml.  The submitted documentation fails to demonstrate the extent or severity of these flares while on the lower dose of medication.  The provider noted that methotrexate is not a viable option due to his current medication (simvastatin).  However, there is no documentation of transaminitis or other medical data to support precluding this medication.  The submitted documentation fails to establish the medical necessity of Enbrel 50mg/ml (twice per week).  All told, Enbrel 50mg/ml (twice per week) was not and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested direct applied behavioral analysis (ABA) therapy (0365T) for treatment of the enrollees autism.  Findings: The physician reviewer found that the request for 18 hours per week (36 units) of direct ABA therapy (0365T), three hours per week (6 units) of oversight (0369T) and four units per month of multi-family treatment guidance (0371T) has not been established as medically necessary for treatment of the patients Autism Spectrum Disorder (ASD). In general, ABA therapy is effective when initiated at an early age, preferably before the age of two (Spreckley and Boyd). For older children and young adults, therapy is generally directed away from ABA therapy toward social skills development (Reichow, et al). In this case, the patient presents with significant issues of language delay, impulsivity, and stereotypical and ritualistic behaviors. The ABA progress report shows a lack of significant improvements over the past six months. As such, a reduction of ABA hours to 10 hours per week of ABA therapy (0365T), two hours per week of oversight (0369T) and two units per month of multi-family guidance (0370T) as authorized by the Health Plan is medically reasonable for treatment of the patients ASD.  Final Result: The reviewer determined that the services at issue 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 with sub-specialty 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Cequa 0.09% eye solution. Findings: In a randomized, double-masked, placebo-controlled trial of patients with an eye dryness score (EDS) of at least 40, a study concluded that lifitegrast, the active ingredient in Xiidra, significantly improved symptoms of eye dryness versus placebo, as measured by EDS. In a multicenter, randomized, double-masked, vehicle controlled study, it was found that 20.5% of study participants receiving Cequa 0.09% achieved a greater than or equal to ten mm increase in their Schirmers tear score, compared to 11.3% of study participants receiving vehicle, and that Cequa 0.09% significantly improved total conjunctival staining over vehicle at week 12. However, these results have so far not been replicated and independently verified by other studies. In a meta-analysis of thirty randomized-controlled trials to evaluate the effectiveness of cyclosporine A (CsA) eye drops in the treatment of dry eye disease, another study concluded that, despite its widespread use, there was inconsistent evidence on the efficacy of CsA on ocular discomfort and on ocular surface and tear-film parameters such as corneal fluorescein staining, Schirmers test, and tear break-up time. Given that the patient is being appropriately treated with Xiidra, and the lack of high-level evidence in current medical literature supporting the efficacy of Cequa in this clinical setting, the requested medication is not medically indicated. Therefore, Cequa 0.09% eye solution is not medically necessary for the treatment of this patient. 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 ophthalmology 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 36-year-old female with multiple sclerosis (MS).  She utilizes a Baclofen pump for management of spasticity and has tried several medications for relief of her painful neuropathy. A trial of Lyrica has successfully treated her symptoms, and she no longer requires narcotic pain medication. The patient has submitted a request for authorization of Lyrica. The Health Plan denied her request based upon a determination that the medication is not medically necessary for treatment of her neuropathic pain.Many patients with MS complain of painful neurological symptoms likely due to the MS plaques situated at the nerve root exit within the spinal cord. Lyrica, although typically prescribed for patients with diabetic neuropathy or herpes zoster, should theoretically provide benefit in the relief of pain resulting from nerve root involvement. Lyrica has been found to be safe and is approved for the treatment of other types of neuropathic pain. The efficacy of Lyrica in treating this patients symptoms has been clearly established by subjective report and objective measures such as the discontinuation of narcotic pain medication. The prescription of Lyrical is a logical and appropriate approach to management of the patients neuropathic pain and is associated with fewer side effects than narcotic pain medications. 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: Medical Necessity
Decision: Overturned

The parent of a three-year-old male enrollee has requested a referral for speech therapy for treatment of the enrollees delayed speech and stuttering. Findings:  The physician reviewer found that stuttering, or speech dysfluency, may be divided into developmental stuttering, neurogenic stuttering that results from neurological problems, and psychogenic stuttering that occurs following psychological trauma. Up to 80% of children who experience developmental dysfluency, or mild pathologic dysfluency, recover spontaneously. However, a certain number of children deteriorate, developing severe dysfluency. Those with non-developmental stuttering also fall within this latter category. They require therapy and counseling in order to recover from the disorder (see Ward and Lawrence and Barclay).This patient presents with multiple speech and language difficulties. It is important to address these deficits with a referral for speech therapy in order to improve his communication skills and prevent difficulties in the future that may not be as amenable to therapy at that point
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old male has requested approval for Xifaxan for treatment of his Crohns disease.   Findings:  The physician reviewer found that the role of antibiotics in the management of Crohns disease remains controversial (Guslandi, et al). Early observational data suggested that metronidazole and ciprofloxacin may be beneficial for Crohns colitis. These agents are generally not helpful in Crohns ileitis or ulcerative colitis. In addition, there is concern that the patients gastrointestinal tract will become colonized with resistant organisms (Kothary, et al). All told, the requested Xifaxan therapy cannot be recommended for long-term IBD management and therefore is not supported as medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A male enrollee requested authorization and coverage of endoscopic gastric plication with EndoCinch. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees gastroesophageal reflux disease (GERD).Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all of the three physician reviewers concluded that the requested surgery is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old male enrollee has requested  for the medication Cialis for treatment of his erectile dysfunction.   Findings:  The physician reviewer found that the etiology of erectile dysfunction in younger patients can be difficult to ascertain. Often type 5-phosphodiesterase (PDE-5) inhibitors like Cialis are used empirically. Some patients will respond to this therapy. This patient appears to have responded positively to Cialis.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for facial feminization services (CPT codes 14020, 21137, 21209, 30520 (RT and LT), 30140 (RT and LT), 30465, and 15824). Facial feminization surgery is medically necessary for many transgender women to help alleviate the psychological distress they experience related to gender dysphoria. The World Professional Association for Transgender Health (WPATH) supports facial feminization surgery to help remedy an incongruent physical appearance and gender identity. In addition, WPATH noted that non-genital surgical procedures, especially facial feminization procedures, are of greater practical significance in a patients daily life than reconstruction of the genitals. The guidelines further report that these reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. Similarly, Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, improved patients mental health-related quality of life. The records provided for review include documentation from several providers who support the patients facial feminization surgeries as medically necessary to help alleviate her significant discomfort due to the masculine features of her face. Given these findings, the facial feminization services (CPT codes 14020, 21137, 21209, 30520 (RT and LT), 30140 (RT and LT), 30465, and 15824) were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Depend brand adult diapers. Urinary incontinence is the involuntary loss of urine. There are several types of urinary incontinence. The diagnosis is mainly based on history and examination. The treatment depends on the etiology of the incontinence. Initial treatment includes lifestyle modifications and pelvic floor muscle exercises for all patients with urinary incontinence (stress, urgency, or mixed), along with bladder training in women with urgency incontinence. Incontinence pads are used when medications or surgical treatments fail to control leaking. In this case, the patient has requested a specific brand of adult briefs or incontinence pads. There is no medical documentation to support that she has had a significant adverse reaction to the pads that are provided by her Health Plan. There is a lack of support for the requested equipment in this setting. Therefore, Depend brand adult diapers are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal 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 patient has requested authorization and coverage for 10 physical therapy sessions. Recovery following shoulder surgery may be prolonged. Gutierrez-Espinoza and colleagues note that supervised physical therapy and home-based progressive shoulder strengthening and stretching exercises for the rotator cuff and scapular muscles are equally effective in patients with subacromial impingement syndrome treated conservatively. Thomson and colleagues report that a systematic review of postoperative rehabilitation recommendations following rotator cuff surgery include exercise therapy, continuous passive motion machines, and aquatic therapy, however, no one rehabilitation protocol was found to be superior to another. The authors further note that the findings of this review suggest that following rotator cuff repair, patients should expect improvement in pain, range of motion, and function. As range of motion and strength are restored and the patient becomes accustomed to the exercises, the program can be transitioned to an independent program, which is a viable and acceptable alternative to formal therapy, unless there are specific documented factors that would preclude an independent program. In this case, the patient is receiving postoperative physical therapy for her left shoulder. She reports various persistent symptoms such as stiffness and weakness at the left shoulder. However, the records do not document impairments or other factors that would preclude transition to an independent exercise program. Further formal physical therapy in this case would not be expected to favorably impact the patients course or outcomes in a clinically significant manner beyond independent exercise, self-applied modalities, and the passage of time. In this clinical setting, given that long-term skilled physical therapy, including supervised exercises and formal passive therapies such as manual therapy, is not generally of proven marginal benefit over an appropriate independent program, the requested services are not medically indicated. Therefore, 10 physical therapy sessions are not medically necessary for the treatment of this patient.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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 30-year-old female enrollee has requested coverage for the medication phentermine 37.5 mg for treatment her obesity. Findings:  The physician reviewer found that review of the submitted clinical information demonstrates the patient has been diagnosed with obesity. Phentermine is an FDA-approved medication for obesity and has been used with good results in some patients. The documentation provided does not demonstrate any contraindications to the use of phentermine in this case. Thus, a course of phentermine is a medically appropriate and reasonable option for this patient. However, the patient will require a prescribing and supervising physician to monitor her for potential risks and complications. In addition, the medication is not indicated for long-term use over three months without a break in treatment. In sum, a three-month course of phentermine 37.5 mg is medically necessary for treatment of this patients obesity.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee requested authorization and coverage of the medication Actiq. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic back pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee requested air and ground ambulance services for treatment of his medical condition. Findings:  The physician reviewer found that air ambulance services are considered medically necessary when specific criteria are met.  Specifically, the air ambulance must have the necessary equipment, the patients condition must be such that transportation other than by air ambulance is medically contraindicated, the patients condition is such that transport by land poses a serious threat to the patients survival, the patient is transported to the nearest hospital with appropriate facilities for treatment, and there is a medical condition that is life-threatening.  The use of air ambulance services to transport a patient from one hospital to another may be indicated if the first hospital does not have the required facilities to treat the patient.  Air ambulance services are not considered medically necessary when the transfer is from one hospital capable of treating the patient to another hospital for the convenience of the patient or patients family, or when the transport is to a hospital other than the nearest one with appropriate facilities.  Although a letter from the provider indicates transfer to the facility in another state was for the best possible outcome, there is a lack of objective evidence in the medical record that one spinal cord rehabilitation facility is more qualified than the other in treating patients with spinal cord injury.  The medical records indicate that the spinal cord injury treatment center from which the patient was transferred was appropriate for this patients level of care. There is no medical justification for transfer to a different spinal cord injury center.  All told, air and ground ambulance services provided were not medically indicated for the treatment of this patient.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 emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.