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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Prolia injections. Findings: A study noted that treatment is generally recommended in postmenopausal women who have a bone mineral density T-score of -2.5 or less, a history of spine or hip fracture, or indications of fracture risk. The U.S. Food and Drug Administration (FDA) indicates Prolia as appropriate for the treatment of postmenopausal women with osteoporosis at high risk of fracture. In this case, given the patients diagnosis of osteoporosis and bone mineral density T-score of -2.5, the requested medication is medically indicated. Therefore, Prolia injections are 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 rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret for eight weeks. 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. This applies to all patients, regardless of fibrosis. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret daily for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret for eight weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) of the left knee for evaluation of the enrollees arthralgia of left lower leg. Findings: The reviewer found that this patients records do not include any documented red flags to indicate immediate imaging of the left knee. Specifically, there is no evidence of trauma, fracture on plain film x-rays or signs of infection. Further, there is no sign of instability. Absent such indications for further imaging, there is no medical indication for immediate MRI of the left knee without a trial of conservative management. Accordingly, the requested MRI of the left knee is not medically necessary.Final Result: The reviewer determined that the requested diagnostic procedure 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 diagnostic radiology 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 patient has requested authorization and coverage for enhanced external counterpulsation (EECP) therapy Currently, EECP is reserved for patients who have no percutaneous or surgical options for the treatment of angina and have failed or cannot tolerate angina treatment with guideline directed optimal medical therapy including higher dose beta blockers, long acting nitrates and calcium blockers and/or ranolazine.There is a lack of cardiac test results including catheterization and stress testing to delineate the extent and treatability of his coronary artery disease.  The pain is described as exacerbated with exertion and relieved with rest, but the level of exertion is not reported. There is also a lack of evidence that the patient has been treated with other anti-anginal agents including calcium blockers, long-acting nitrates, or ranolazine. His resting heart rate and his blood pressure allow for further medical therapy. Based on the available information, the patients condition is not consistent with refractory angina to support an indication for EECP. For these reasons, the requested EECP therapy is 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 internal medicine with subspecialty certification in cardiovascular disease 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for psychiatric emergency services. Based on the available documentation, this patient does not meet Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for postpartum depression because the onset of her symptoms started more than four weeks following the birth of her child. She did struggle with anxiety and sleep deprivation related to her childs difficulty sleeping. However, the records do not document that the patient was at serious risk for suicide, self-harm or harm to others. She was provided with timely therapeutic intervention from several resources and she did not meet the criteria for emergency care. Accordingly, the emergency services provided were not necessary for treatment of a psychiatric emergency medical condition. Thus, the patient did not receive psychiatric emergency medical services on the dates of service at issue.Final Result: The reviewer determined that the services at issue were not necessary for treatment of a psychiatric 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

This patient is an 11-month-old male with a diagnosis of brachycephaly and plagiocephaly. With brachycephaly, the predominant condition measurements demonstrate a cephalic index greater than 2 standard deviations above the norm and an asymmetry of the cranial vault of 4.5 mm. At issue is whether a cranial remodeling orthosis is medically necessary for treatment of the patients brachycephaly and plagiocephaly.Review of the medical evidence demonstrates that a cranial orthotic does not improve brachycephaly. Plagiocephaly of 4.5 mm without evidence of brachycephaly often corrects with time and positioning. The only study looking at both plagiocephaly and brachycephaly (Teichgraker) documents little effect on brachycephaly. For these reasons, the requested device is not likely to be of clinical value in this setting and is not medically warranted. Based upon the information set forth above, I have determined the requested device is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old male enrollee has requested five doses of Synagis for respiratory syncytial virus (RSV) prevention.  Findings:  The physician reviewer found that in a survey of pediatric specialists who care for children with chronic medical conditions that are technology dependent, almost 90% recommended RSV immunoprophylaxis, and over half recommended immunoprophylaxis for children older than two years (Panitch, et al). In another study of 282 hospitalized children, 22% were older than 12 months, and were more likely to have underlying chronic diseases. These authors concluded that children older than 12 months with underlying disease are at increased risk for serious or fatal RSV infections and are not always protected by previous RSV disease. Such older children should be considered candidates for passive or active immunoprophylaxis against RSV infection as such agents become available. (Groothuis, et al.)This patient is a young child at risk for severe RSV disease. He is technology dependent because of his hypoplastic left heart syndrome complicated by chronic lung disease and severe pulmonary hypertension. It is thus medically necessary and appropriate to administer Synagis for RSV prophylaxis to this patient for the duration of the 2011-12 RSV season. Synagis administration should begin immediately to avoid patient morbidity, and should continue for the full duration of the season as tracked by the Centers for Disease Control and Prevention.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old male enrollee has requested for Fentora 800 mcg for treatment of his Guillain-Barre disease.  Findings:  The physician reviewer found that there are no studies in the literature that support the use of Fentora in neuropathic pain or in the patients specific syndrome, ascending polyneuropathy and Guillain-Barre disease. Other opiates as well as the anti-convulsants have been studied for their efficacy in Guillain-Barre syndrome. However, as concluded by Pandey and colleagues, buccal fentanyl (Fentora) has not been examined for this disease. Its efficacy for the treatment of the patients condition has not been established.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee requested lumbar spinal fusion for medical treatment of her low back pain.  Findings:  The physician reviewer found that the current medical evidence does not support lumbar spinal fusion in this clinical setting.  There is a lack of evidence provided within the documentation that the patient has radiological evidence of spondylolisthesis, segmental instability, failed previous operation, or evidence that the patient had developed stenosis above or below a previous fusion surgery.  Additionally, there is a lack of rationale provided as to why the patient is a better candidate for lumbar fusion versus less invasive surgical operations, such as laminectomy and/or discectomy.  All told, lumbar spinal fusion is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested genetic testing for medical evaluation of her basal cell skin cancer and family history of breast cancer.  Findings:  The physician reviewer found that while the recommendations vary somewhat from group to group, between the American College of Medical Genetics (ACMG) and the American Society of Breast Surgeons (ASBS), patients who are candidates for genetic testing to assess cancer predisposition require a family history of early onset breast cancer, a previously identified BRCA1 or BRCA2 mutation in the family, Ashkenazi Jewish ancestry and breast cancer at any age, and more than three cases of breast, ovarian, pancreatic and/or aggressive prostate cancer in close relatives, including the patient.  All told, the requested genetic testing is not supported as medically necessary for evaluation and treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Nutropin AQ NuSpin 10 mg pen injector for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that This patient is underweight for height and has mild constitutional delay. However, the records do not support a diagnosis of growth hormone (GH) deficiency as an explanation of his relative short stature. His height is not more than two standard deviations below the mean for age and gender, his peak GH response on provocative GH testing was normal, and he has no known morphological abnormalities of his pituitary gland. Although his predicted adult height is more than two standard deviations below his mid-parental target height, it falls within the range of normal for U.S. adult males. Thus, GH therapy with the requested Nutropin AQ NuSpin 10 mg pen injector is not medically necessary for 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: Upheld

A 38-year-old male enrollee has requested for acupuncture for treatment of his weight control and digestion.    Findings:  The physician reviewer found that no evidence to support acupuncture for the treatment of constipation. There are numerous available safe and effective remedies (e.g., high dose fiber sorbitol and PEG) for constipation. These remedies are addressed in the review articles referenced above. In addition, there is no evidence to support the use of acupuncture to control or reduce excess body weight. As such, the use of acupuncture in this setting is not medically justified.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old male enrollee has requested authorization and coverage for speech therapy for treatment of the enrollees speech language disorder.  Findings:  The physician reviewer found that based on review of the available records, this three-year-old patient is intellectually normal, but he is frustrated by his inability to make himself understood, as 50% of his speech is unintelligible. His articulation defect is not due to a developmental delay, but is secondary to neurological dysfunction of his brain/oral pharynx/tongue network. His difficulty stems from a developmental abnormality in his nervous system. Tyler concluded that reviews of the literature support the necessity and effectiveness of speech therapy in children over three years of age with articulation defects. In addition, Sharp and Hillenbrand report that two-year olds, who tested below the 10th percentile for age, require and will benefit from speech therapy. This patient has a specific congenital defect in his brain circuitry and qualifies for speech therapy within their definition. All told, it is medically necessary that this patient receive two hours of speech therapy per week.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested physical therapy for treatment of the enrollees muscular hypotonia.  Findings:  The physician reviewer found that it is difficult to determine if a hypotonic infant can improve with the aid of physical therapy. A hypotonic muscle would not be expected to increase its tone by an exercise protocol. However, physical therapy can be useful in following a child and ultimately directing clinical evaluation toward a correct diagnosis (Malerba and Tecklin). Reus and colleagues described reliable physical therapy techniques that can improve muscle strength in infants and young children. Mintz-Itkin and colleagues conducted a controlled study of 29 hypotonic infants divided into two groups which received either weekly or monthly physical therapy. The authors reported that the patients who received weekly physical therapy began walking at 15 months while the patients who received monthly therapy were significantly delayed beyond 15 months. Thus, there is a role for physical therapy in the treatment of hypotonic infants. This patient was consistently improving in the physical therapy records until services were discontinued in the month specified. Given the support in the medical literature, the requested physical therapy is medically necessary for treatment of this patients medical condition. The duration of physical therapy would be dependent on the patients progress.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of the enrollees coronary artery disease. Findings:  The physician reviewers found that based on the records provided the patient presents with increased coronary risk and documented coronary ischemia on stress testing. In this circumstance guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations.  These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. For the reasons provided, the advanced lipoprotein testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the testing 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. Physician reviewer number one, two, and three are board certified in internal medicine with sub-specialty certification in cardiovascular disease and actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for high intensity focused ultrasound (HIFU). The U.S. Food and Drug Administration (FDA) approves HIFU as a minimally invasive treatment approach to ablate prostate tissue. Maestroni and colleagues report that a systematic review of literature revealed that HIFU is effective in the treatment of clinically localized prostate cancer. Given that current medical literature supports the efficacy of HIFU in this clinical setting, the requested service is medically indicated. Therefore, HIFU 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old male enrollee requested authorization and coverage for metal-on-metal hip resurfacing. The health plan denied this request indicating that the requested procedure is considered experimental for treatment of the enrollees osteoarthritis.All three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the health plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Ativan. The U.S. Food and Drug Administration (FDA) approved indications for Ativan support short-term use for relief of the symptoms of anxiety or anxiety associated with depressive symptoms. Anxiety or tension associated with the stress of everyday life usually does not require treatment with an anxiolytic. The recommendations include treatment with Ativan for up to four weeks, with extensions based on reevaluation findings to support continued therapy. Per the FDA, continuous long-term use of Ativan is not recommended. In recent guidelines for the treatment of anxiety disorders, Bandelow and colleagues noted that treatment should include psychological therapy, pharmacotherapy, or a combination of both. Cognitive behavioral therapy can be regarded as the psychotherapy with the highest level of evidence. First-line drugs are the selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors. The authors concluded that benzodiazepines are not recommended for routine use. The records provided for review document that this patients provider did not recommend continued treatment with Ativan, noting the patients misuse of medications and complex mental health history. The providers decision to not recommend Ativan, a benzodiazepine, is consistent with the FDA approval as well as the guidelines outlined by Bandelow and colleagues. Due to his history of substance abuse and chronic anxiety symptoms, the patient is at elevated risk of tolerance and dependence with benzodiazepines. Moreover, the patients records do not document that the patient has exhausted first-line therapies for anxiety. For these reasons, the requested Ativan 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 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.