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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vemlidy. Guidelines for the treatment of hepatitis B recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. The patient has already failed entecavir (Baraclude).  In comparison with tenofovir disoproxil fumarate (Viread), which the patient has been taking, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects, such as osteopenia and renal disease. The medical evidence supports the requested medication in this clinical setting. All told, Vemlidy 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: Overturned

A 52-year-old female enrollee has requested Bayer Contour test strips for treatment of her insulin dependent diabetes mellitus.   Findings:  The physician reviewer found that review of the submitted documentation demonstrates the medical necessity of the requested equipment. The patient has a history of insulin dependent diabetes mellitus for which she uses an insulin pump, hypertension, elevated blood pressure and obesity. According to American Association of Clinical Endocrinologists (AACE) guidelines, intensive glycemic control is necessary in this patient with insulin dependent diabetes to prevent progression of retinopathy and nephropathy. This patient has been using a Medtronic Minimed insulin pump to control her sugars. She is currently using a Bayer Contour meter and test strips along with her existing insulin pump. The True Results glucose meter authorized by the Health Plan is not compatible with the patients Medtronic Minimed pump. As such, continued use of the Bayer Contour meter and strips is medically necessary. Therefore, the requested Bayer Contour strips should be authorized.
Appeal type: Medical Necessity
Decision: Upheld

A 69-year-old male enrollee has requested Orthovisc injections for treatment of his bilateral knee osteoarthritis.  Findings:  The physician reviewer found that when possible, it is oftentimes best to temporize and postpone total joint replacement because of routine operative risks and the known cumulative effects of wear debris from metal and methylacrylate bearing surfaces. A younger patient will be exposed to longer duration of particulate exposure and will have an increased risk of localized bone resorption and prosthetic subsidence, as well as both abrasive and contact wear of the components. Despite the advantages of delaying total joint replacement in this patient, the efficacy of hyaluronan injection preparations is poorly supported in the medical literature and patients undergoing these treatment protocols are vulnerable to a powerful placebo effect. In the study cited above by Jorgensen and colleagues, a double-blind placebo controlled administration of intra-articular Hyaluronate demonstrated no efficacy in patients studied at 3, 6, 9 and 12 months after injection when compared to physiological saline. Repeated injections are not without potential complications including aseptic inflammatory response and possible septic arthrosis. Given the lack of clinical data supporting the utility of viscosupplementation therapy for this patient, the medical necessity of the requested Orthovisc injections has not been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. The Health Plan denied the services at issue as not medically necessary.The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.Regarding the six LOCUS dimensions, the patient has a low risk of harm. The records document that he has not expressed any suicidal or homicidal ideation or intent (score 1). Regarding functional status, he is minimally impaired and has maintained activities of daily living and employment (score 1). His comorbidities include alcohol use disorder (score 2). The patients recovery environment is minimally stressful with a stable housing situation (score 1) and the patients family is supportive (score 1). The patient has had a significant response to treatment, given his absence of depressive symptoms and sobriety (score 1). Moreover, he participates in therapy and attends Alcoholics Anonymous and Gamblers Anonymous meetings (score 1). For a LOCUS composite score of 8, the recommended level of care is basic services which consistent of outpatient treatment with a therapist and psychiatrist.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients behavioral health 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: Overturned

The parent of a 13-year-old male enrollee has requested Nutropin for treatment of the enrollees hypothalamic growth hormone deficiency. Findings:  The physician reviewer found that according to the Lawson Wilkins Pediatric Endocrinology Societys recent guidelines, a trial of growth hormone (GH) therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: height more than 2.25 standard deviations (SDs) below the mean for age or more than 2 SDs below the mid-parental height percentile; growth velocity below the 25th percentile for bone age; bone age more than 2 SDs below the mean for age; low serum IGF-1 and/or IGFBP-3; and/or other clinical features suggestive of GH deficiency. This patient meets most of the above criteria based on the information provided. As such, a trial of GH therapy is medically warranted for treatment of the FDA-approved indication of idiopathic short stature with poor adult height potential. After a trial of GH, the patient should be re-evaluated to determine the necessity of continued GH treatment, based on response to therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 41-year-old female enrollee requested authorization and coverage of a gastric stimulator (Enterra Therapy) for the treatment of gastroparesis.  The health plan denied the enrollees request indicating that the requested equipment is considered investigational.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Two physician reviewers concluded that the requested gastric stimulator is likely to be more beneficial for treatment of the enrollees gastroparesis than any available standard therapy.  Because two of the three physician reviewers concluded that the requested equipment 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: Medical Necessity
Decision: Upheld

A 51-year-old male enrollee has requested total knee replacement surgery for treatment of his left knee pain with grade 4 chondromalacia.  Findings:  The physician reviewer found that overall, it is not in the best interest of this patient to proceed with TKR at this time. The reasons for this decision are both case specific and reference the general problems of TKR in patients 55 and younger. The specific considerations with regard to this patient include an elevated BMI and multiple co-morbidities. It is likely that his left leg pain has multiple pain generators including the lumbosacral spine, sacroiliac joints, and the hip joints. His provider also makes reference to an ankle arthritic process. The patients anatomical, x-ray, and MRI studies do not document advanced degenerative osteoarthritis of the left knee. The most predictable benefit from resurfacing the left knee through TKR would come if the patient had evidence of such advanced changes. In addition, the long-term complications of TKR are significant such that temporary alternative treatments should be utilized as remedial measures whenever possible. The additional long-term concerns include particulate wear debris, which is likely to cause issues in immediate proximity to the prosthesis. Moreover, the prosthesis is likely to wear and loosen. The literature cited above provides convincing evidence that TKR will have its best efficacy in patients 65 and older. Treatment options have been discussed with this patient and according to his records, not all conservative measures have been exhausted. These options include weight control with isokinetic exercise, a trial of a medial unloader brace, and the use of a walking aid on the opposite side of his body, which is likely to give him substantial symptomatic relief.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Botox for treatment of the enrollees migraine headaches. Findings:  The physician reviewer found that this patients provider documented more than 15 headache days a month for two months. Underreporting of headache frequency is typical as patients often only include the severe and disabling migraines, and do not mention the milder headaches that respond to medications like Excedrin. Botox is the only preventive medication approved by the U.S. Food and Drug Administration (FDA) for treatment of chronic migraine as demonstrated in the PREEMPT II trial. All told, the requested Botox is more likely to be effective than standard therapies for treatment of this patients chronic migraine. Final Result: All three reviewers determined that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in 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

A 52-year-old female enrollee requested authorization and coverage for Enbrel injections. The health plan has denied this request indicating that the requested injections are not medically necessary for treatment of the enrollees 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested removal of gastric band and revision of gastric sleeve for treatment of her medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The patient underwent the laparoscopic adjustable gastric band  without documented complication or intolerance.  Given the lack of any documented anatomic complication, intolerance, and lack of any updated multidisciplinary evaluation to determine whether she would be a reasonable candidate for revision, the medical necessity of the requested procedure is not established.  All told, the requested removal of gastric band and revision of gastric sleeve are not medically indicated 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 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for transcranial magnetic stimulation 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 requested services. The American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder. However, the recommendation does not extend to personality disorders or bipolar disorder. Although some preliminary positivism regarding the application of transcranial magnetic stimulation therapy for patients with bipolar disorder can be found in the medical literature, there is an absence of well-controlled and adequately powered exploratory and confirmatory studies. The medical evidence does not support the requested services in this clinical setting. All told, transcranial magnetic stimulation is 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 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

A 20-year-old male enrollee has requested for all in one catheter for treatment of the enrollee, who is status post gunshot wound resulting in paraplegia. Findings:  The physician reviewer found that there is a lack of support in the medical literature demonstrating a benefit to the all in one catheter system for the prevention of infections.  While the current medical evidence supports the use of self-lubricating catheters, there is a paucity of support for the requested all in one catheter in this patients case.  All told, the requested all in one catheter is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old male enrollee has requested total laparoscopic surgery (esophagectomy) for treatment of his esophageal adenocarcinoma.  Findings:  The physician reviewer found that the medical necessity of total laparoscopic transhiatal esophagectomy is not established for treatment of this patients condition, as the Ivor Lewis esophagectomy is accepted standard of care management for distal esophageal cancer. It has been shown in a retrospective study (Nguyen, et al.) that minimally invasive Ivor Lewis esophagectomy using combined thoracic and laparoscopic approach has shorter operative time, decreased blood loss, fewer transfusions and decreased ICU stay compared to open transthoracic and transhiatal esophagectomy. To date, there are no randomized, prospective studies documenting improved patient outcomes in a direct comparison of total laparoscopic transhiatal esophagectomy and the Ivor Lewis esophagectomy. While there is some data suggestive of the promise afforded the laparoscopic transhiatal esophagectomy, there is inadequate data to support a finding that it is superior to the minimally invasive Ivor Lewis procedure. For these reasons, the requested procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female enrollee has requested laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) bariatric surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that with a BMI of 39 and comorbid conditions this patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. Peer reviewed articles demonstrate superior weight loss and maintenance of weight loss over the long term with BPD/DS as compared to other surgical procedures. The published data also demonstrates that the Roux-en-Y procedure offers no advantage in regard to protein calorie malnutrition and may even have more severe consequences. This patient has significant metabolic syndrome, and BPD/DS is the treatment of choice for her obesity.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old male enrollee has requested a whole body PET/CT imaging for evaluation of his adrenal abnormalities. Findings:  The physician reviewer found that whole body PET/CT imaging is a useful adjunct to more conventional imaging studies in select oncologic and cardiac situations or to evaluate seizure foci in patients who are surgical candidates for treatment of intractable epilepsy. This patient has no documented malignancy and no suspicious findings on conventional imaging (CT and MRI). PET/CT imaging has not yet been proven to be useful for the evaluation of metabolic disorders such as Cushings disease or to search for an underlying malignancy when conventional imaging is unremarkable.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy and occupational therapy services for the treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that the medical literature suggests that language deficits are one of the core aspects of autism for which speech therapy is recommended. Rogers and Vismara noted that speech therapy provides patients with ASD professional assistance and guidance on communication development. In addition, Stone and Yoder evaluated 34 children with autism at 2 years of age with follow-up at 2 years. The patients with significant speech and language intervention were noted to have improved in their development of speech and language skills. The authors examined factors related to the development of spoken language and found the only significant predictors were motor imitation and number of hours of speech and language therapy. Moreover, Goldstein conducted a peer-review of the available clinical research published over the past 20 years and concluded that the evidence supports the effectiveness of therapeutic interventions to teach communication skills to children with autism. This young patients evaluations document a history of severe expressive and receptive language delays and socialization deficits. Based on the patients documented deficits as well as the scientific evidence supporting speech therapy for patients with autism, the requested speech therapy is medically necessary for this patient with ASD. With regard to occupational therapy, the occupational therapy evaluation indicated the patient had fine motor delays but was unable to participate in standardized testing due to behavioral and/or cognitive limitation. Given that the evaluation was affected by the patients behavior and lack of cooperation, a re-evaluation of the patients gross motor and fine motor skills using objective observation and measurement should be performed to determine if true deficits exist. Thus, an occupational therapy evaluation is medically indicated and necessary for this patient in order to determine the appropriateness of occupational therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested residential treatment center level of care for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  This patient required residential admission based on her noncompliance, rapid weight loss, and inability to be stabilized on an outpatient or partial hospital basis.  Subsequently, the patient was more cooperative and was not so overtly rebellious that her behavior could not have been managed at a lower level of care.  Her weight was more stable, and she was intermittently orthostatic.   All told, the submitted records support the medical necessity of eating disorder residential treatment center level of care initially, but not thereafter.  Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.