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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested corrective hip surgery for treatment of his medical condition.  The physician reviewer found that the peer-reviewed literature supports revision total hip arthroplasty as useful to address femoral offset restoration and leg length equalization in patients with functional limitations when a surgically correctable cause of limb-length discrepancy can be identified.  Forster-Horvath and colleagues concluded that there was no universal definition of leg length discrepancy after total hip replacement, but there was a consensus that less than 10 mm was acceptable.  The authors found that the underlying cause was femoral component malpositioning in the vast majority of cases which led to significant limping, lower back pain and nerve palsy.  The authors recommended that revision surgery without knowing the underlying pathology should be avoided.  In this case, the patient reported daily left lateral hip and thigh pain radiating to the knee.  Clinical examination findings were consistent with iliotibial band syndrome and the provider opined this was likely secondary to leg length discrepancy.  The radiographs demonstrated at least 5 mm of leg length discrepancy and evidence of increased offset. There was no evidence of hardware loosening, malposition, or infection.  Detailed evidence of a reasonable and comprehensive less invasive treatment trial, for example shoe lift correction trial and failure, has not been submitted.  Significant improvement in strength and muscle activation was reported with recent physical therapy with ongoing treatment noted.  All told, the requested corrective hip surgery is 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 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

The parent of a 35-month-old male enrollee has requested authorization and coverage for individual speech therapy at a frequency of 2 sessions per week for 30 minutes per session for treatment of the enrollees expressive language disorder and childhood apraxia of speech. Findings:  The physician reviewer found that the patient has a history of an expressive speech delay of greater than 40%.  Speech therapy is indicated with any delay greater than 25% (Law, et al.). Improvements have been noted following speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty (Law, et al.). Treatment for language disorders is predicated primarily on the childs language profile and level of communication skills (Feldman and Messick). Children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman and Messick). Childhood apraxia of speech is a condition where children have difficulty with the controlled production of speech sound and it is presumed to be neurologic in origin (Feldman and Messick). Intensive treatment levels are needed to help children with this speech disorder learn to produce sounds in syllables of increasing complexity (Feldman and Messick). Gallagher, et al. evaluated speech and language interventions for preschool children with specific language impairment and found statistically greater improvement with intensive direct speech therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. All told, the requested speech therapy is medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for whole-body positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan (CPT 78816/HCPCS A9552). The National Comprehensive Cancer Network guidelines in oncology for occult primary do not support the use of routine PET scans for cancer surveillance. Rather, PET scans are typically used in patients with known or suspected cancer for staging and guiding diagnostic or therapeutic decision making. In this case, the patient is asymptomatic. In this clinical setting, the requested service is not medically indicated. Therefore, whole-body positron emission tomography (PET) with concurrently acquired CT scan (CPT 78816/HCPCS A9552) is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for evaluation 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 27-year-old female enrollee has requested insertion of electrode for percutaneous tibial nerve stimulation and implantable neurostimulator electrode treatments for treatment of her interstitial cystitis.  Findings:  Two physician reviewers found that for patients with interstitial cystitis, multiple interventions are often necessary, with a combination of behavioral changes, pelvic floor physical therapy, counseling, oral medications, and bladder instillations. Hormonal manipulation in premenopausal women with menstrual flares may also provide benefit. Recently, continuous sacral nerve stimulation has been applied as an alternative, less-invasive therapeutic option for patients with lower urinary tract dysfunction not responding to conservative treatment. At this time, the current peer-reviewed literature fails to support percutaneous tibial nerve stimulation as an effective treatment for interstitial cystitis. This technique requires further study in order to establish its superior efficacy in this case.  Thus, the services at issue were not and are not likely to be superior over all other treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for methylergonovine maleate 0.2 mg tablet, three (3) times daily (90 tablets/30 day supply).The submitted documentation supports that the requested medication is medically necessary. Methylergonovine maleate is an ergot derivative with vasoconstrictive properties, and it has been cited as an effective treatment for vascular headaches, more specifically migraines. Studies of patients who have used methylergonovine maleate have found that patients reported significant relief from migraines. In this case, the patient has been struggling with cycles of severe headache pain, and she has been on multiple traditional medical therapies for the treatment of her migraines without relief. Under these circumstances, the requested methylergonovine maleate 0.2 mg tablet, three (3) times daily (90 tablets/30 day supply) is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the nasal/sinus endoscopy, surgical balloon dilation. Findings:  The physician reviewer found that according to the medical reports submitted, this patients symptoms included nasal congestion and episodes of recurrent sinusitis. The patient was shown to have enlarged inferior turbinates. Traditionally, endoscopic endonasal surgery, ethmoid sinus surgery, and maxillary sinus surgery are the mainstays of surgical intervention for the treatment of chronic sinus disease. However, there was no documentation in the medical reports submitted that the patient had evidence of continuous sinus disease other than nasal congestion. Overall, this patient does not meet the clinical criteria for surgical treatment of the paranasal sinuses. Given these findings, the nasal/sinus endoscopy, surgical balloon dilation was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. One reviewer found that a portion of the nasal/sinus endoscopy, surgical balloon dilation was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: One reviewer is board certified in otolaryngology and is actively practicing. One Reviewer is board certified in otolaryngology and is actively practicing.  One Reviewer is board certified in otolaryngology and is 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Trulance tablet for treatment of the enrollees Crohns disease. Findings:  The physician reviewer found that there is support in the medical literature for the requested medication in this clinical setting. Trulance has been proven effective in a multicenter, randomized, double-blinded, placebo-controlled Phase III clinical trial.  In this case, the patient reports failure of three formulary alternatives and a failure of Amitiza. The patient reported a good response to Trulance, which is an effective alternative.  For these reasons, the request for Trulance tablet is supported as medically necessary for the treatment of the patients medical condition.  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: Experimental/Investigational
Decision: Overturned

A 51-year-old female enrollee has requested Alimta for treatment of neuroendocrine small cell cancer.  Findings:  Two physician reviewers found that Alimta has been studied in refractory small cell lung cancer with response rates of approximately 20%. Alimta does appear to be an active drug in these diseases and as such, offers greater potential for an improved outcome than any standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old male enrollee has requested a Synvisc injection for treatment of his knee pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested Synvisc injection in this patients case.  The requested service is not likely to be beneficial for the treatment of this patient.  The current medical evidence does not support the requested Synvisc injection.  There is a documented incidence of aseptic inflammatory reactions due to allergic response, and there is a risk of iatrogenic infection within the joint.  Rutjes and colleagues conducted a systematic review and meta-analysis assessing the risks and benefits of viscosupplementation for adults with symptomatic knee osteoarthritis.  The authors concluded that viscosupplementation is associated with an increased risk for adverse events and a clinically irrelevant benefit.  All told, the requested Synvisc injection is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 51-year-old woman with chronic insomnia who is requesting drug coverage for Lunesta 6mg per day. The following is a summary of her clinical course.According to the records, the patient had a severe thumb injury 10 years ago. Multiple surgical repairs resulted in chronic pain and the patient was diagnosed with reflex sympathetic dystrophy (RSD). A consult dated June 2005 by the patients sleep specialist reviewed her history including multiple bouts of depression and anxiety. The patient had been tried on various sleep aids in the past. The sleep specialist prescribed melatonin and Lunesta at 6 mg per day. The sleep specialist had noted that this dose was not FDA-approved but she found it was effective for some patients.The patients psychologist supports the use of Lunesta at 6 mg per day stating that it will help prevent future psychiatric hospitalizations. The patients psychiatrist states that the patient has depression, severe anxiety and borderline personality disorder and that lack of sleep will trigger aggressive behavior and mood instability. The psychiatrist has recommended Lunesta at 6 mg per day.The Health Plan has denied coverage for the prescribed dose because it exceeds the FDA-approved dosage of 3 mg per day.The Health Plans denial should be upheld. The enclosed prescribing information states that doses of Lunesta from 1 to 6 mg per day were tested in individuals and there were no significant issues in drug clearance and elimination. The prescribing information did include a section on Drug Abuse and Dependence. It states that the risk of abuse and dependence on Lunesta is greater for patients who have a history of psychiatric disorders. It also states that at doses two-fold or greater, a dose-related increase in reports of amnesia and hallucinations was observed.There is current evidence to suggest that a dose beyond 3 mg of Lunesta is more efficacious but there is also the question of safety. Use of Lunesta in the United States is recent and until more studies on dosing are provided, it is prudent to adhere to the FDA-approved doses. Therefore, I have determined that the requested prescription is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 56-year-old male enrollee requested authorization and coverage of prolotherapy for the treatment of sacroiliac joint pain.  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 prolotherapy is likely to be more beneficial for treatment of the enrollees sacroiliac joint pain 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: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee requested authorization and coverage for an increase in dosage of the medication Celebrex. The health plan has denied this request indicating that the request is not medically necessary for treatment of the enrollees low 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 increase in the enrollees prescription dosage is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for mifepristone (Korlym) 300 mg tablet. Findings:  The physician reviewer found that Korlym is U.S. Food and Drug Administration (FDA) approved for use in patients with Cushings syndrome who are not candidates for surgery. However, this patients records do not meet the criteria for a diagnosis of Cushings. In addition, there is a lack of documentation demonstrating that the patient has excessive cortisol levels or pseudo-Cushings syndrome. Hence, the requested mifepristone (Korlym) 300 mg tablet is not supported as medically necessary for treatment of this patients medical condition. 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 endocrinology, diabetes and metabolism 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 Adderall XR 15 mg daily. This patients records support a diagnosis of ADHD, predominantly inattentive type, which was diagnosed in childhood. The provider reported that the patient has been treated with Adderall XR, Concerta, and Focalin XR. Given the patients longstanding diagnosis of ADHD and reported benefit in her ADHD symptoms from the previous medication regimens, the patient is an ideal candidate for continued treatment for her ADHD. The patients provider has recommended treatment with Adderall XR 15 mg, which has been beneficial for the patient in the past. Per Geffen and Forster, Stimulants are first-line pharmacologic agents for adult ADHD with a long history and moderate to large effect. The authors commented further that, Long-acting formulations allow once-daily simple treatment regimens so in the real world they are more effective than short-acting preparations and less prone to abuse/diversion. This patients provider noted that treatment with Adderall IR is not recommended for this patient due to the potential risk for tolerance and dependence. The provider charted that the patient has a long history of positive response to Adderall XR 15 mg daily. Given these findings, the requested Adderall XR 15 mg daily is medically necessary for treatment of this patient. The requested medication is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, Adderall XR 15 mg daily is clinically appropriate in terms of type, frequency, extent, site, and duration. Adderall XR 15 mg daily is not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.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 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 57-year-old male enrollee requested authorization and coverage for a referral to an out-of-network surgical oncologist. The health plan has denied this request indicating that the requested referral is not medically necessary for treatment of the enrollees 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 referral is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Namenda for treatment of his multiple sclerosis with cognitive deficits. Findings:  The physician reviewer found that there is a lack of support in the medical literature demonstrating that memantine has a therapeutic effect in the treatment of MS related cognitive disorder. He and colleagues performed randomized controlled trials (RCTs) involving 625 patients with relapsing-remitting, secondary-progressive and primary-progressive MS, evaluating the absolute efficacy of donepezil, ginkgo biloba, memantine and rivastigmine versus placebo in improving memory performance with diverse assessment scales. The authors concluded that We found no convincing evidence to support the efficacy of pharmacological symptomatic treatment for MS-associated memory disorder because most of available RCTs had a limited quality. Whether pharmacological treatment is effective for memory disorder in patients with MS remains inconclusive. Given the lack of support in the medical literature, the requested medication is not medically necessary for treatment of the patients medical condition.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 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: Overturned

The parent of a 38-year-old male enrollee has requested for inpatient psychiatric treatment services for treatment of the enrollees paranoid schizophrenia and major depressive disorder. Findings:  The physician reviewer found that a review of the inpatient progress notes clearly indicates the patients illness was quite severe. Moving forward with conservatorship was appropriate given this severity along with the absence of insight and frequent medication noncompliance. A vital part of his inpatient treatment plan was to ensure that conservatorship and subsequent placement were obtained, allowing for a safe discharge. In addition, progress notes thoroughly document the acuity of the patients condition and the extent of his delusions and his paranoia up until his transfer.