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

The patient is a 50-year-old male with severe asthma. A letter dated 11/3/03 from the patients pulmonologist states the patient has severe asthma based on his symptoms and pulmonary function tests. The patients FEV1 was 57% in September 2002 and declined to 41% in October 2003. The patients pulmonologist states the patient was on inhaled steroids. His IgE level was elevated at 343 IU/ml. The patient reports he has a family history of sudden asthma death. The patients provider started the patient on Xolair and has recommended that the patient continue on the drug. The Health Plan has denied authorization and coverage for Xolair on the basis it is not medically necessary for treatment of the patients asthma.Xolair is indicated in patients with moderate to severe asthma, positive skin test reactivity to aeroallergens, and an IgE level greater than 30. Xolair is useful in patients who are on inhaled steroids and leukotriene modifier drugs and still have poorly controlled asthma. Use of systemic steroids such as prednisone should be avoided because of a myriad of adverse effects, especially in this patient who is obese and has already undergone coronary artery bypass grafts.According to the records provided, the patient had been on inhaled corticosteroid and a leukotriene modifier. The patients clinical condition improved when he was started on Xolair. Use of Xolair is indicated in this patient since his asthma was not controlled on his previous regimen. There has been demonstrated improvement in the patients condition since Xolair was initiated. Given these results and in light of the patients other medical problems, use of Xolair is medically appropriate and indicated. Therefore, I have determined that 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

A 55-year-old male enrollee has requested a functional electrical stimulation (FES) cycle ergometer RT 300 device for treatment of his tetraplegia.  Findings:  Two physician reviewers found that the patient has developed osteoporosis, with a history of multiple fractures.  He has also developed multiple skin lesions resulting in infection, and osteomyelitis resulting in surgical repair. Functional electrical stimulation has been found to be beneficial for patients with chronic spinal cord injury who are unable to exercise on their own.  Benefits in circulation, muscle mass, bone health and skin integrity have been demonstrated. This patient has tetraplegia and is unable to strengthen his extremities volitionally.  The alternative treatment is passive range of motion by another individual.  The FES cycle ergometer RT 300 device is likely to be more beneficial than this alternative. FES intervention will prevent complications and comorbidities related to the patients spinal cord injury.  Thus, the requested device is likely to be of greater benefit than other treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested buprenorphine HCL for medical treatment of her Crohns disease.  Findings:  The physician reviewer found that buprenorphine will likely exacerbate the patients constipation and worsen the patients condition. Baron and McDonald reported that chronic opiates have side effects that do not dissipate with time including constipation, respiratory depression, and may contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. It would therefore be in the best interest of the patient to wean down or off all opiates as this could reduce her incidence of opioid-induced hyperalgesia and other adverse effects, including constipation. For these reasons, the requested buprenorphine HCL is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested a 12 week course of Harvoni for medical treatment of his hepatitis C virus.  Findings:  Two physician reviewers found that the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment guidelines for managing and treating patients with HCV state the following,  Immediate treatment is assigned the highest priority for those patients with advanced fibrosis (Metavir F3), those with compensated cirrhosis (Metavir F4), liver transplant recipients, and patients with severe extrahepatic hepatitis C.  Per the treatment guidelines, Harvoni for 12 weeks is medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested laparoscopic anti-reflux surgery (LINX) for treatment of her medical condition.  Findings:  Two physician reviewers found that the U.S. Food and Drug Administration (FDA) approved the LINX Reflux Management System for lower esophageal sphincter augmentation. Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate GERD and a hiatal hernia less than 3 cm. The device is a ring made up of a series of magnets that have sufficient attraction to increase the lower esophageal sphincter (LES) closure pressure, but allow for food passage with swallowing. While the results from early studies at four years are encouraging, there was no control group. This patient may have supra-esophageal or extra-esophageal symptoms of GERD. This is a particularly difficult subgroup of individuals to treat because symptoms are often multifactorial and respond poorly to measures to reduce proximal acid reflux. In this subgroup, surgical fundoplication has shown disappointing results and is generally not recommended. Similarly, there is limited medical evidence from controlled trials that the LINX device would be beneficial in this subgroup. Based on the limited of evidence of benefit, even in heartburn patients, and in particular the subset with supra-esophageal GERD, the requested procedure is not likely to be more efficacious than standard therapy in treatment of this patients medical condition.   Final Result: Two reviewers determined that the requested procedure is 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:   All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three 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

A 30-year-old male enrollee requested authorization and coverage of continued licensed vocational nurse (LVN) home health care for the treatment of C3-4 Tetraplegia.  The Health Plan denied the enrollees request indicating that the requested home health care is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old transgender female enrollee requested breast augmentation surgery for medical treatment of the enrollees gender dysphoria.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates the patient experiences gender dysphoria related to her masculine chest appearance. Despite many years of treatment with hormone replacement therapy, the patient has failed to achieve adequate breast development. The next appropriate step in the clinical treatment of the patients condition is a breast augmentation procedure.  The appearance of the patients chest is not considered normal for her female gender, and thus, is considered an abnormal structure of the body. This condition is caused by gender dysphoria, which is widely regarded to be either congenital in nature or a result of an early developmental issue. The proposed surgery is necessary to normalize the patients chest appearance to the female gender. The consensus among the providers who have evaluated the patient is that surgery will provide a significant improvement in the appearance of the patient. I concur with this assessment based upon the photographs provided and the clinical information submitted for review. Thus, the requested breast augmentation surgery meets criteria for reconstructive surgery in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Nexium 40 mg DR. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients gastroesophageal reflux disease (GERD) with esophagitis. The submitted documentation supports the medical necessity of the requested medication. The American College of Gastroenterology guidelines for gastroesophageal reflux disease (GERD) recommends proton pump inhibitor (PPI) therapy for patients with GERD and esophagitis. A comparison of multiple formulary PPIs attempted by the patient, including omeprazole, lansoprazole, rabeprazole, and pantoprazole, has found no difference in control and healing of GERD, which is supported by medical literature. It is unlikely that a re-trial of these medications would be effective. Additionally, the American College of Gastroenterology guidelines for Barretts esophagus states that patients with Barrett's esophagus should receive once-daily PPI.  Current medical guidelines support continued PPI therapy when a patient has failed all other available PPIs. The patient has also reported that he has had significant improvement with Nexium. For these reasons, Nexium 40 mg DR is medically necessary for the 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 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: The patients parent has requested authorization and coverage for Humatrope. Findings: Somatotropin (brand name Humatrope) may be indicated for pediatric use for specific conditions, including pediatric growth hormone deficiency so long as epiphyses, or growth plates, remain open. In this case, a bone age study reported a chronological age of 17 years and two months and a bone age of 18 years, a stage consistent with closed epiphyses. The records documented a lack of growth. In this clinical setting, given that the submitted records show evidence consistent with closed epiphyses, the requested medication is not medically indicated. Therefore, Humatrope 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 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

The parent of a nine-year-old male enrollee has requested  speech therapy for treatment of his autism. Findings:  The physician reviewer found that the literature demonstrates that children with autism benefit from intensive intervention that focuses on increasing the frequency, form and function of communicative acts. Yoder and McDuffle noted that past research has shown that object play, non verbal communication and useful speech are all influenced by various types of interventions in young children with autism, suggesting that therapy is indicated. The standard of care adopted by the medical community as set forth in the evidence based guidelines for autism developed by the American Academy of Neurology and Child Neurology Society includes speech therapy. Specifically, the guidelines state that the evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach, including one or more of the following professionals: psychologists, neurologists, speechlanguage pathologists and audiologists, pediatricians, child psychiatrists, occupational therapists, and physical therapists. Given the available peer reviewed medical literature and the patients documented expressive and receptive language delay, the requested speech therapy is medically necessary for treatment of his condition.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested for shower legs  and pool physical therapy for treatment of her medical condition. Findings:  The physician reviewer found that this patient has demonstrated a significant level of independence, given the complexity of her medical condition and multiple co-morbidities. Nevertheless, there is inadequate medical literature to support the notion that pool physical therapy is medically necessary over land-based therapy. In regard to the request for shower legs, there is no current peer-reviewed medical literature supporting the use of shower/waterproof types of prosthesis devices as being necessary for bathing. Due to safety reasons, standing inside a shower on a wet surface is contraindicated for patients who are status post bilateral amputation. Sitting in a shower chair or a tub bench and taking a bath or utilizing a hand held shower are more appropriate options for this patient population.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Everolimus 5 mg, 30 tablets per month. This patient presents with recurrent glioblastoma. Per the provider, the patient has been treated with resection and chemotherapy including a clinical trial with nab-rapamycin at 60 mg per day, at least six weeks of radiation with temozolomide, and four cycles of adjuvant treatment with nab-rapamycin and temozolomide. The patients provider has recommended treatment with everolimus given the patients recurrence. Everolimus is not U.S. Food and Drug Administration (FDA) approved for the treatment of glioblastoma. Moreover, current major drug compendia and the National Comprehensive Cancer Network (NCCN) guidelines does not recommend treatment with everolimus for patients with recurrent glioblastoma (Nabors, et al.). The use of everolimus has been studied in patients with lower grade tumors, such as subependymal giant cell astrocytoma, but not glioblastoma which is a high grade tumor. A phase II trial of everolimus in recurrent glioblastoma failed to show efficacy (Cloughesy, et al.). Therefore, the requested Everolimus 5 mg, 30 tablets per month is not medically necessary for 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 subspecialty 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for 24 weeks for treatment of his chronic hepatitis C virus genotype 1a. Findings:  Three physician reviewers found that Harvoni was approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic hepatitis C genotype 1 infection in both treatment-naive and treatment-experienced patients. Per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. FDA approved antiviral therapy regardless of fibrosis score. The recommended treatment duration depends on prior treatment experience and the presence or absence of cirrhosis. Cirrhotic genotype 1 patients who have failed prior therapy with peginterferon and ribavirin are recommended to be treated with Harvoni for 24 weeks. Thus, the requested treatment with Harvoni for 24 weeks is supported as medically necessary for treatment of this patients medical condition.  Final Result: Three reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three 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 three-year-old male enrollee has requested social cognitive speech and language therapy, sensory integration (auditory, tactile and oral motor), and occupational therapy (tactile, vestibular, and proprioceptive functions) for treatment of the enrollees autism. Findings:  The physician reviewer found that social cognitive speech and language therapy, sensory integration, and occupational therapy are well-established modalities for the treatment of autism. Myers and colleagues state in their seminal paper that, Most children with ASD can develop useful speech. Goldstein and colleagues discussed the various speech therapy modalities and their effectiveness in autistic children. Turner and colleagues reported that the earlier and more intensive speech therapy an autistic child receives, the better the prognosis for normalized speech. Similarly, Paul and Sutherland emphasize that early intervention and intensity of speech therapy is essential for young autistic patients to develop meaningful speech. Of further note, Schaaf and Miller document the support in the medical literature for the effectiveness of sensory integration and occupational therapy in the autistic patient. They conclude that improvement in the ability to process and integrate sensory input will influence adaptive behavior and occupational performance. Furthermore, a case study by Roberts, et al. reported on improved behavior regulation following treatment with classical sensory integration therapy. The paper by Chase-Smith, et al. is a report of controlled studies of occupational therapy interventions in autistic children. These studies confirm that occupational therapy can be successful in this population.In conclusion, given the severity of this patients documented deficits, he is an appropriate candidate for major intervention involving multiple modalities. For these reasons, the requested social cognitive speech and language therapy, sensory integration, and occupational therapy services are medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for inpatient behavioral health level of care services for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that this patient presents with a serious, chronic mental illness that has required specialized medical care including treatment with clozapine, an antipsychotic medication typically reserved for patients with refractory psychotic illnesses. The records indicate that the acute episode of illness that prompted the admission has improved as the patient is eating well, sleeping restfully and taking his medication. However, the patient continues to require inpatient behavioral health level of care services. Due to the considerable impairment, past history and poor prognosis, a premature or inappropriate discharge would only serve to increase the patients chances of a prompt re-admission, while exposing the population to potential risk of harm. The patient requires a locked and supervised setting with trained medical professionals, including access to psychiatric specialty care. While the inpatient treatment team works to place the patient in a residential facility for long-term treatment of his behavioral condition, continued inpatient services are appropriate. Thus, the inpatient behavioral health level of care services provided were and are medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were and 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 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.