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

A 45-year-old female enrollee has requested additional physical therapy at a skilled care facility for treatment of her medical condition. Findings:  The physician reviewer found that there is general agreement that skilled rehabilitation is appropriate for individuals with a hip fracture. However, there is no consensus on the effectiveness of different therapeutic programs (i.e., in terms of intensity, duration, and frequency). The need for continued skilled rehabilitation depends on the individuals response to therapy and whether further gains are likely. This patients weight bearing status was toe-touch weight bearing. The patient required minimal assistance with her bed mobility, transfers, and walking. She required moderate assistance in most activities of daily living. The patient was independent in bed mobility and transfers on and required stand-by-assistance with walking (using a front-wheeled walker). The records indicate the patient either required stand-by-assistance or was independent in her activities of daily living. Per the physical therapy note, the patient had met her goals by ambulating greater than 100 feet with stand-by-assistance with her walker and was independent with her bed mobility and transfers. She had also met her occupational therapy goals. The patient was trained in safety and exercises and instructed on how to follow her weight bearing precautions. The physical therapy notes conclude by stating that the patient was ready to be discharged. All told, the patient made significant progress in her rehabilitation program. Although she required stand-by-assistance with ambulation, and likely still requires this level of assistance with ambulation, it is not necessary for this assistance to be provided by skilled therapists. The submitted evidence does not demonstrate that the patient has functional deficits that require additional skilled physical therapy at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee requested authorization and coverage of intensity modulated radiation therapy (IMRT). The Health Plan denied the enrollee's request indicating that the requested therapy is not medically necessary for treatment of the enrollees prostate cancer.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The mother of a 14-year-old female enrollee requested authorization and coverage of a Dolomite Legacy front-wheeled walker. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees cerebral palsy with spastic quadriplegia. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested equipment is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for air and associated ground ambulance transportation services. Researchers notes that rehabilitation is an important aspect of the continuum of care in strokes resulting in functional deficits. In this case, the patient received inpatient rehabilitation after her stroke and made significant improvements. At discharge, the records noted supervision to contact guard assistance level of assistance for most functions. The records did not document clinically significant cognitive deficits or behavioral impairments. The patient was eating a regular oral diet and did not require critical care or other continuous, hands-on medical or nursing care. The patients family members, including her spouse and daughter, were present at the facility and learning to provide support and care.  The patient had the option of continuing rehabilitation locally until she could be cleared to fly home commercially, or otherwise return home via ground transportation to northern California. Given that this was an elective, non-emergent transfer for the convenience of the patient and her family, the services at issue were not medically indicated. Therefore, air and associated ground ambulance transportation services 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 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: Upheld

A female enrollee requested Benlysta 11.6 mg/kg (920 mg) infusions for medical treatment of her systemic lupus erythematosus.  Findings:  The physician reviewer found that per the current medical literature, Benlysta has been evaluated in major clinical trials at doses of 1, 4, and 10 mg/kg.  A review of the literature did not find support for use of dosages above 10 mg/kg.  There is not sufficient information available to indicate that a dose of 11.6 mg/kg is medically indicated in this patients case.  All told, Benlysta 11.6 mg/kg (920 mg) infusions are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 1a. 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 recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including Zepatier when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 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: Upheld

A 53-year-old female enrollee has requested authorization and coverage for bilateral knee Supartz injections for treatment of the enrollees knee pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The value of viscosupplementation has been generally accepted as a technique in the treatment of osteoarthritis of the knee, and it is considered most suitable for patients with mild to moderate disease.  However, there is a lack of agreement on the efficacy of repeat treatment courses, with a lack of available evidence supporting repeat treatment.  While some reports have been encouraging, other reports have shown an increased rate of adverse reactions in patients with multiple courses of therapy.  The current medical evidence does not support the requested services in this patients case.  All told, the requested bilateral knee Supartz injections are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested hip surgery for treatment of her medical condition.   Findings:  The physician reviewer found that researchers reported on a series of surgical interventions with arthroscopic endoscopic repair of partial or full thickness tears combined with bursectomy. The authors state that their findings need to be confirmed by clinical studies with longer follow-up and that the degree of tendon degeneration may compromise any attempts to repair the lesion present. Based on the documentation submitted for review, the patient has substantial and significant comorbidities. Any surgical intervention would likely have low efficacy and high risk of complications, such that it is not likely to be beneficial. Based on the peer-reviewed literature and clinical documentation the requested hip surgery is not clinically indicated for the treatment of the patients medical condition.  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 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: Upheld

The patient has requested authorization and coverage for platelet-rich plasma (PRP) epidural injections for the cervical spine and thoracic spine. The American Society of Interventional Pain Physicians (ASIPP) guidelines state that based on best evidence synthesis principles based on a single systematic review, and five individual studies, the evidence for management of low back and lower extremity pain with epidural biologic injections has been assessed as level four out of five for PRP. The ASIPP concluded that the available studies provide limited evidence for PRP injection therapy in the management of discogenic pain. In this case, the patient has signs and symptoms suggestive of cervical radiculopathy. The records document that he has failed several conservative therapies including non-steroidal anti-inflammatory drugs (NSAIDs), a transcutaneous electrical nerve stimulation (TENS) unit, stretching, and opioid therapy. Following thorough evaluation and examination, the patients providers have recommended cervical fusion and epidural steroid injections. The patient has declined these options and is requesting PRP epidural injections. Overall, the current evidence for PRP injections for back and extremity pain is weak. There are insufficient high quality demonstrating that PRP is effective for treating cervical radiculopathy or thoracic spine pain. Based on the available medical records, the requested PRP epidural injections for the cervical spine and thoracic spine are not medically necessary for 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 anesthesiology with subspecialty certification in pain management 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 substance abuse partial hospitalization treatment for treatment of her behavioral health condition. Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings optimize treatment gains.  However, episodic placement in more restrictive settings is often clinically appropriate for those with serious addictive illness.  The patient had a long history of addiction that had impacted all functional domains of living.  On the date indicated, she had not yet consolidated the treatment gains necessary to succeed in a less restrictive setting.  The patient remained ambivalent and was still experiencing withdrawal symptoms of irritability and insomnia, in addition to craving that was addressed with a naltrexone prescription.  The current medical records support the services at issue in this clinical setting.  The treatment provided was reasonably expected to improve the patients condition while preventing a more serious episode of illness.  All told, substance abuse partial hospitalization treatment was medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam radiation therapy. Findings:  The physician reviewer found that The submitted documentation supports the medical necessity of the requested services. The medical literature indicates that treatment with proton beam radiation therapy offers a clinical benefit compared to conventional radiation therapy techniques for lung cancer in this clinical setting. Due to this patients diagnosis of Li-Fraumeni syndrome and necessity of treating the mediastinum and hilum, treatment with protons is likely to decrease his risk of developing cardiac and pulmonary complications and a secondary radiation-induced malignancy. Patients with Li-Fraumeni syndrome benefit from treatment with proton beam radiation therapy because of the lower integral dose which would lead to lower secondary malignancies compared to photon techniques. Proton beam radiation therapy would reduce the heart and lung dose in this case. Therefore, proton beam radiation therapy 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 radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old male enrollee has requested for the medication Focalin XR for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). Findings:  The physician reviewer found that no information has been submitted demonstrating that either Adderal of Concerta is contraindicated for this patient. Adderal or Adderal XR or Concerta all have the potential to provide significant benefit for this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for transcranial magnetic stimulation (TMS). TMS therapy is U.S. Food and Drug Administration (FDA) approved for the treatment of patients in the acute phase of major depressive disorder. The criteria for TMS therapy includes persistent depressive symptoms as well as failure of four trials of psychopharmacologic agents, including two different agent classes, and two augmentation trials. This patient has been treated with at least five different antidepressants including a selective serotonin reuptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitor (SNRI). She also underwent two augmentation trials, which included Wellbutrin and Abilify. Perera and colleagues reported that TMS is supported for patients with major depressive disorder who have not responded to antidepressant medications. The authors concluded that TMS has substantial evidence of efficacy and safety for treating the acute phase of depression in patients who are treatment resistant or intolerant. Given these findings, the TMS services 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Monovisc injection in the left knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of left knee pain due to patellofemoral osteoarthritis of three years duration. Treatment has included arthroscopic debridement, physical therapy, and non-steroidal anti-inflammatory drugs (NSAIDs). As the remaining treatment options are limited, the requested Monovisc injection  in the left knee is medically necessary for 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Daavlin Home Phototherapy system (HCPCS E0694 - UV multidirectional light therapy system in 6 foot cabinet).At issue is whether the requested Daavlin Home Phototherapy system (HCPCS E0694 - UV multidirectional light therapy system in 6 foot cabinet) is medically necessary to treat the patients condition for any of the following: to prevent disease, disability, and other health conditions or their progression; to prolong life; to promote physical and mental health and efficiency; to correct or ameliorate any physical or behavioral conditions.Vitiligo is an acquired cutaneous depigmentation disorder which causes loss of melanocytes in the skin and mucosa. Vitiligo is an autoimmune disease, and depigmentation can evolve throughout a patients life. Vitiligo has major effects on self-esteem and social life, and quality of life is highly impaired in patients with this disease. Topical treatments may be applied alone when small areas are involved or when other treatment modalities are not readily available. Phototherapy combined with topical treatment is preferred when less than five to ten percent of the BSA is affected or when focal areas are unresponsive to topical treatments alone. Although several interventions are available to treat patients with vitiligo, no definite cure has yet been developed. Phototherapy, including psoralenultraviolet-A (PUVA) and NBUVB therapy, constitutes the principal treatment modality for generalized vitiligo.In this case, the patient requires treatment three times a week for an extended period. The home therapy unit for treatment of this disease would be necessary to prevent progression and to promote physical and mental health. Therefore, the requested Daavlin Home Phototherapy system (HCPCS E0694 - UV multidirectional light therapy system in 6 foot cabinet) is medically necessary to prevent disease, disability, and other health conditions or their progression.Final Result: The reviewer determined that the requested equipment 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a seven-year-old male has requested a mitochondrial muscle biopsy for evaluation of his stated condition of a possible metabolic/mitochondrial disorder.  Findings:  The physician reviewer found that this patient has ASD but does not exhibit other symptoms to suggest a mitochondrial disorder. Signs of mitochondrial disease include elevations of lactic acid, which the patient does demonstrate.  However, blood lactate and pyruvate measurements are known to be prone to erroneous increases due to such issues as prolonged tourniquet application, (see Bonini, et al. and Haas). Other biochemical markers are often present including elevation of plasma alanine in the amino acids, elevations of urine organic acids and especially dicarboxylic acids due to omega oxidation of fat in the cytoplasm when mitochondria are not functioning normally.  Elevations of acylcarnitine derivatives are usually seen, as well.  Ammonia can also be elevated with mitochondrial disease (Haas). The patient exhibited none of these biochemical markers. Finally, patients with mitochondrial diseases usually have progressive deterioration in their neurological functioning (Haas) which is also not evident in the documentation provided regarding this patient. Therefore, without additional signs or symptoms as outlined above, a muscle biopsy for the purpose of a mitochondrial disease work-up is not medically necessary for the patient.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested a 12 week course of Harvoni for treatment of his hepatitis C virus genotype 1b.  Findings:  Three physician reviewers found that the patient has moderate fibrosis per Fibroscan, but the interpretation between F2 and F3 fibrosis is challenging (Afdhal, et al). This patient has elevated liver function testing with probable significant inflammation and high viral load. In this clinical setting, the requested 12 weeks of Harvoni is supported by the American Association of the Study of Liver Diseases and the Infectious Diseases Society of America as medically necessary.