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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Colestipol Hcl tablets. Findings:  The physician reviewer found that bile acid malabsorption diarrhea can occur in patients with Crohns disease who have had ileal resection. The use of Colestipol can be effective for the treatment of bile acid malabsorption diarrhea. The records indicate that this patient has failed Welchol and Imodium and has been successfully stabilized on Colestipol for many years. For these reasons, Colestipol Hcl tablets are supported as medically necessary for the treatment of this patients chronic diarrhea. Final result: The reviewer determined that the requested medication is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 45-year-old female enrollee requested authorization and coverage of botox injections for the treatment of severe and chronic headaches.  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 botox injections are likely to be more beneficial for treatment of the enrollees severe and chronic headaches than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization overturned the health plans denial.
Appeal type: Experimental/Investigational
Decision: Overturned

A 27-year-old female enrollee requested Kalbitor for medical treatment of the enrollees hereditary angioedema.  Findings:  Two physician reviewers found that given the life-threatening nature of this patients condition and documented failure of high-dose antihistamines and steroids, it is prudent to make Kalbitor available to her in an emergency (Bork, et al; Kaplan). There are currently limited diagnostic tests available to test the bradykinin pathway to prove the mechanistic pathophysiology of this patients disease. Based on the clinical observations and lack of response to classic treatments, it is likely that bradykinin is involved in the patients disease process. Accordingly, the empiric treatment results support the likelihood that the requested Kalbitor will be more beneficial for treatment of this patients medical condition than any available therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for clindamycin infusion for treatment of the enrollees connective tissue disease and scleroderma. Findings:  The physician reviewer found that currently, the treatment of scleroderma or systemic sclerosis involves organ specific therapy. The current medical literature fails to support the treatment of scleroderma with clindamycin. The medical literature for minocycline and scleroderma reveal that this medication is ineffective in the treatments of systemic sclerosis. The authors found that the change in the MRSS (Modified Rodnan skin thickness score) was similar to that expected in the natural course of this disease. Based on these data, minocycline is not an effective therapy for systemic sclerosis. Researchers reported that rituximab improved patient health outcomes when compared to matched control groups. The authors concluded that rituximab demonstrated improvement of skin fibrosis and prevention of worsening lung fibrosis, supporting the therapeutic concept of B cell inhibition in systemic sclerosis. In this case, the patient has active lung disease and skin disease, overlap disease. The current literature supports rituximab therapy for the treatment of overlap syndrome. In addition, in patients with interstitial lung disease, rituximab prevented significantly the further decline of FVC compared with matched controls. Overall, the literature does not support clindamycin as a recommended therapy for the treatment of scleroderma and overlap syndrome. 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 internal medicine with sub-specialty certification in rheumatology 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 is requesting reimbursement for Euflexxa injections. Findings: Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patients options are limited. The patient has tried and failed other conservative treatments, including oral nonsteroidal anti-inflammatory drugs (NSAIDs), topical diclofenac, physical therapy, and a corticosteroid injection, with the alternative being a total knee arthroplasty. The medical evidence supports the services at issue in this clinical setting. Therefore, the Euflexxa injections received were medically necessary for the 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 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

A 45-year-old female enrollee has requested Zofran 8mg for treatment of post-chemotherapy nausea.   Findings:  The physician reviewer found that optimal management of chemotherapy induced nausea and vomiting involves assessment of risk, use of an appropriate prophylactic regimen, and management of breakthrough symptoms. She has received a very good prophylactic regimen. Given that she has had delayed emesis despite this regimen, it is reasonable to add a prepitant such as Zofran to her prophylactic regimen.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for bilateral mastectomy. World Professional Association for Transgender Health (WPATH) criteria for chest surgery state that chest surgery in female-to-male patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. The intent of this suggested sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role, before undergoing irreversible surgery. However, different approaches may be more suitable, depending on an adolescents specific clinical situation and goals for gender identity expression.Based upon the clinical history and documentation provided, this patient meets the WPATH criteria for breast surgery. This patient has been on testosterone therapy since March 2016 and has been living in the chosen gender role for greater than one year. Based on the documentation provided, this patient understands the risks, benefits, limitations and alternatives to surgery. His medical, mental health, and surgical providers are also supportive. Based on the records, surgery is medically necessary to align his body with his gender identity. Surgery would allow for him to stop binding, which is causing him discomfort and skin irritation and will likely help address his social anxiety. Therefore, the requested bilateral mastectomy is medically necessary for the treatment of this patient.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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and expertise in transgender care 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 requested residential treatment center services for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  She was medically stable.  She was not functionally or cognitively impaired.  With the exception of adding one medication, her medications had not been changed since admission.  Her family was supportive and participated in family sessions.  She was active in her therapies.  It was not medically necessary for the patient to remain in a 24-hour, supervised residential setting.  All told, residential treatment center services provided during the period at issue were not medically necessary 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype DX Prostate Cancer Assay. Findings:  The physician reviewers found that once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by the analysis of certain features, such as the grade of tumor and prostate-specific antigen level.  This helps guide the most appropriate therapy for patients taking into account their age and comorbidities.  Many patients will not require therapy and may be followed closely instead.  The important features to recognize are Gleason score and prostate-specific antigen, but these are imperfect. Thus, current biomarkers are inadequate for risk stratification, and better prognostic biomarkers are needed. Oncotype DX Prostate Cancer Assay is a gene expression analysis of target genes in the biopsy specimen that generates a genomic prostate score.  The genomic prostate score identifies patients with very low risk disease that can be followed rather than referred for surgery. The current prognostic features are inadequate to make firm recommendations regarding active surveillance to patients. The medical evidence supports the services at issue to better stratify such patients with localized disease.  Thus, Oncotype DX Prostate Cancer Assay performed was likely to have been of greater benefit than other modalities for evaluating this patient. Final Result: 2 of 3 reviewers determined that the services at issue were 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: 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: Overturned

The parent of a four-year-old male enrollee has requested occupational therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that the medical necessity of occupational therapy utilizing sensory integration for the treatment of this patient with autism is medically necessary based on overall evaluation of the literature, including positive analysis from Myers, et al. At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and can be utilized to improve overall neurologic health. Thus, specific treatment, including occupational therapy with an emphasis on sensory integration, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not irrevocably compromised by the underlying pathogenetic process. Given this patients deficits, the requested occupational therapy services are strongly supported by the scientific data as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for eight weeks for treatment of her chronic hepatitis C virus genotype 1b.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C 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 the AASLD/IDSA guidelines, Harvoni is first-line therapy for treatment-naive genotype 1 patients. Noncirrhotic patients with viral load below 6 million IU/mL can be treated with Harvoni for eight 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. AASLD guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Harvoni for eight weeks is supported as 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: Overturned

The patient is a 39-year-old female who has had low back pain for over a year with intermittent episodes of left leg radicular pain.  An MRI of the lumbar spine performed in October 2004 showed grade I spondylolisthesis at L5-S1 and a bulging disc at L4-5. The patient was recently seen by an orthopedic surgeon for acute exacerbation of her left leg pain and numbness and was started on medication as of September 2005. An MRI was ordered at that time, but authorization was denied by the Health Plan. The patient had no improvement and saw her provider again in October 2005, at which time they discussed surgical intervention. The patient indicated she was unable to do much physiotherapy due to her pain and discomfort. Authorization for an MRI was requested again and denied. At issue in this case is whether an MRI of the lumbar spine is medically necessary.In general most back pain is treated with medication and physical therapy with no need for imaging. The submitted records are not clear about how much physical therapy the patient has participated in. However, this patient is beyond the status of uncomplicated back pain. She has a documented alignment abnormality of her lumbar spine and experiences intermittent episodes of radicular pain. With this new acute exacerbation of her leg pain, she has been evaluated by a specialist, had a trial of medication, and is now a possible candidate for surgery.  The requested MRI is required to identify any changes from the prior MRI and to assess the patients current condition.  It is also a critical component in the surgeons evaluation.  Based upon the information set forth above, I have determined the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient behavioral health services for her behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The medical record does not demonstrate that psychiatric services provided in a less restrictive setting would have been unsafe or inadequate during the dates of service in dispute. Upon admission, the psychiatrist described the patient as dramatic with chronic suicidal ideation. The nursing assessment documented positive suicidal ideation, although the patient reported that she had fleeting thoughts to harm herself, but would never do that. She expressed a desire to live and identified her family as her primary protective factors. The following day, the patient was euthymic and denied suicidal thoughts. There was no evidence of psychosis, grave disability or an unsupportive home environment. The patient wanted to be hospitalized for the first Electroconvulsive Therapy (ECT) treatment. However, this practice is not consistent with typical community practice standards. Thus, admitting a patient to the hospital solely for purposes of initiating Electroconvulsive Therapy (ECT) is not medically indicated. In sum, although symptomatic and in need of specialty care, the patient was not experiencing an acute psychiatric syndrome. Service delivery in a less restrictive setting would have been safe, appropriate and reasonably expected to improve her condition. Thus, inpatient behavioral health services provided were not medically necessary 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 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

The parent of a 12-year-old female enrollee requested orthodontic services for medical treatment of the enrollees overjet and overbite.  Findings:  The physician reviewer found that the records submitted do not document a medical condition or significant impairment caused by the malocclusion. The patient presents with mild to moderate displacement of the teeth, a score of 7 on the HLD index with no documentation of any handicapping situation or health issues caused by the dentition. For the reasons provided, the orthodontic services were not dentally necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Mvasi. Findings:  The physician reviewer found that  for the treatment of metastatic colorectal cancer, with intravenous 5-fluorouracil based chemotherapy for first or second line treatment, or with fluoropyrimidine-irinotecan or fluoropyrimidine-oxaliplatin based chemotherapy for second line treatment in patients who have progressed on a first line bevacizumab product-containing regimen. In this case, the patient has stage IV colon cancer, and has progressed on a combination of oxaliplatin and irinotecan. While single agent therapy may be reasonable, the requested medication is not medically indicated in combination therapy with FOLFOXIRI. Therefore, Mvasi (Q5107) 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 internal medicine with sub-specialty certifications in medical oncology and hematology 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.