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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for a 30 day supply of Zoloft.The medical literature does not support that the brand name medication Zoloft has superior efficacy over the generic medication sertraline for the treatment of obsessive compulsive disorder (OCD). Researchers conducted a comparative study of the effectiveness of generic versus brand medications. After analyzing data from more than 3.5 million patients, the authors observed that use of generics provided comparable clinical outcomes to those of the brand-name products for chronic conditions including depression and anxiety. American Academy of Child and Adolescent Psychiatry (AACAP) guidelines indicate that selective serotonin reuptake inhibitors (SSRIs) are the initial medication of choice for pediatric OCD due to their efficacy and generally well tolerated side effect profile. SSRIs shown to be effective and safe in this population include fluoxetine, fluvoxamine, and sertraline. If a patient has not demonstrated a response to generic sertraline 250 mg every day, the likelihood is low that brand name Zoloft would result in a superior response, as the generic medication has the same active content as the brand name medication. In this case, there is no clear clinical documentation of the patients ongoing symptoms, no clear history of treatment except for a list of the patients past medication trials, and no clear description of the patients response to previous treatments. There is no indication that the patient was treated with any other medication for treatment of symptoms related to OCD such as another SSRI such as fluvoxamine or fluoxetine. Under these circumstances, the requested 30 day supply of Zoloft is not medically necessary to treat the patients condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat the patient's condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry, with subspecialty certification in child and adolescent 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 32-year-old female enrollee requested authorization and coverage for a continuous positive airway pressure machine (CPAP) for the treatment of sleep apnea.  The health plan denied the enrollees request indicating that the requested CPAP is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested CPAP is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc injections.Findings:  The physician reviewer found that evidence based medical peer-reviewed literature supports the use of Synvisc injections for the treatment of pain in patients with osteoarthritis of the knee. However, there are no current medical studies that support the use of these injections in the treatment of symptomatic medial plica. Literature generally supports surgical excision for recalcitrant cases of symptomatic plica that has undergone irrevocable morphological changes. This patient presents with chronic bilateral knee pain that significantly limits his physical activities. Clinical examination findings documented bilateral knee medial plica that was thickened and painful to palpation. He has reported benefit with prior Synvisc One injections. He has failed physical therapy, medications, and corticosteroid injections. However, there is no imaging or radiographic evidence of osteoarthritis or articular cartilage pathology in the submitted medical records to support the medical necessity of Synvisc injections. 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the medication ocrelizumab (Ocrevus) for treatment of her relapsing remitting multiple sclerosis (MS). Findings:  All three physician reviewers found that the medical literature supports the use of Ocrevus in relapsing remitting multiple sclerosis. Additionally, this medication is approved by the U.S. Food and Drug Administration. The record indicates that this patients clinical status is most consistent with relapsing remitting multiple sclerosis.  In the early years of her diagnosis, while on various injectable therapies, she has experienced numerous relapses with accumulated disability and periods of remission.  Disease and disability progression was halted upon transition to natalizumab. Her contrast enhanced magnetic resonance imaging corroborates her clinical picture, as this has been stable. Contraindications include active hepatitis B infection and history of life threatening infusion reactions to ocrelizumab, neither of which the patient has. Based on the documentation provided and the medical literature, ocrelizumab (Ocrevus) is likely to be more effective than the available standard therapies for treatment of this patients medical condition. Final Result: Three reviewers determined that the requested medication 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: Three reviewers are board certified in neurology and are actively practicing. The reviewer 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for injections of platelet-rich plasma (PRP) provided on 11/06/20, 5/12/21, 6/10/21, and 7/15/21.Findings: Two out of three physician reviewers found that injections of PRP provided on 11/06/20, 5/12/21, 6/10/21, and 7/15/21 were not likely to have been more beneficial for you than any available standard therapy.Mao and colleagues state, Most studies suggest that subcutaneous injection of PRP is likely to reduce hair loss, increase hair diameter and density in patients with androgenic alopecia. Because of the low quality of the studies, small sample sizes, different treatment regimens and possible publication bias, the results of this meta-analysis should be interpreted with caution. Furthermore, more randomized controlled studies should be performed. Hesseler and Shyam advocated the use of PRP for alopecia. However, they noted further studies were needed to provide reproducibility and standardization. They concluded, This review advocates for the use of PRP in three to four monthly sessions for the treatment of alopecia. Further, Gupta and colleagues concluded that based on the available studies, it is difficult to determine the efficacy of PRP in scarring alopecia conditions. While platelet-rich plasma does hold some promise in the use of alopecia, further well-designed studies are needed to confirm a benefit and establish standardized treatment protocols for the preparation, timing and execution of the injections. In this case, the nature of the patient's diagnosis is unclear based on the submitted records. Additionally, the patient was noted to have normal scalp hair distribution and texture on 10/02/20. Based on the medical literature, more studies are needed to establish the benefit from PRP treatment. Therefore, injections of PRP provided on 11/06/20, 5/12/21, 6/10/21, and 7/15/21 were not likely to have been more beneficial for treatment of the patients condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in plastic surgery. All reviewers are 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

The parent of a 10-year-old male enrollee has requested Excimer laser treatments for treatment of the enrollees segmental vitiligo.  Findings:  The physician reviewer found that according to Schwartz and Janniger, vitiligo is an acquired pigmentary disorder of the skin and mucous membranes characterized by circumscribed depigmented macules and patches that cause significant morbidity due to cosmetic disfigurement. Segmental vitiligo manifests as one or more macules in a dermatomal or quasidermatomal pattern. Lotti and colleagues reported that treatment for vitiligo is difficult and prolonged. Although many therapeutic options exist and new modalities are still emerging, treatment challenges persist as not all patients respond to available therapies. Thus, variables that affect the choice of treatment include the extent, distribution, and progression rate of the lesions. Medical treatments include topical corticosteroids and other topical treatments, such as Protopic. Segmental vitiligo can be treated with narrow-band ultraviolet B, monochromatic Excimer light and psoralen phototherapy (Mahmoud, et al). The Excimer laser is a type of phototherapy that focuses directly on individual lesions of and penetrates deeper into the skin. The Excimer laser has the advantage of treating only involved skin, therefore minimizing potential risks of exposing normal-appearing skin to UV radiation. However, treatment periods of more than 12 weeks may be necessary to obtain satisfactory clinical repigmentation particularly when vitiligo lesions are treated only once or twice per week compared with 3 times weekly (Hofer, et al). The important clinical aspects of this patients vitiligo, the attempted and failed treatments, as well as the results of clinical research trials of Excimer laser in the treatment of vitiligo, support Excimer laser therapy as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene expression profiling test for evaluation of the enrollees uveal melanoma. Findings: Three physician reviewers found that this patient has a rare disease, ocular melanoma. The Collaborative Ocular Melanoma Study Group Report No. 26 by Diener-West and colleagues demonstrated equivalent survival in patients treated with brachytherapy versus enucleation. Knowledge of the propensity for metastasis directly affects surveillance of patients by computed tomography scan. Along these lines, clinical studies have been done using the gene expression classifier DecisionDX UM, which defines two classes of ocular melanoma. Class I is associated with a low risk of metastasis and class 2 has a 50% risk at two years and 72% risk at five years. This gene expression classifier is discussed in the Physicians Data Query of the National Cancer Institute. There is very limited standard prognostic indicator that could serve as an alternative for evaluating this rare ocular melanoma. Thus, the current medical evidence favors the use of this genetic testing in the postoperative surveillance of patients diagnosed with ocular melanoma. For these reasons, the gene test (gene expression profiling) performed was likely to be more beneficial than any other available methods in the evaluation of this patient.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are 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

The parent of a one-year, six-month-old male enrollee has requested occupational therapy and physical therapy for treatment of the enrollees delayed developmental milestones. Findings:  The physician reviewer found that this patient was extremely premature with a prolonged neonatal hospital stay and relatively few complications for his gestational age. However, the patients overall motor and cognitive development are delayed and his prematurity should no longer affect adjusting his development parameters. Thus, he clearly has developmental and motor delays likely consistent with a diagnosis of cerebral palsy, spastic diplegia. There is a robust medical literature establishing the medical need and value of OT and PT in the physically and developmentally delayed pediatric population. Arpino and colleagues conducted a meta-analysis of many controlled studies demonstrating improvement in motor skills resulting from PT. In addition, Novak and colleagues reported significant advancements with even a relatively short period of intensive OT treatment. Given this patients delays, the requested services have been established as medically necessary and are supported as a well-established standard of treatment. Specifically, the patient should receive two hours weekly of both PT and OT services weekly with re-assessments at 6 and 12 months for progress reports and updated goals.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for referral to a gastroenterologist. In this case, the patient has experienced protracted symptoms, including changes in bowel habits, which warrant evaluation. Additionally, the patient has a history of positive fecal immunochemical test results for blood in the stool. In the setting of a change in bowel habits and a prior history of colorectal cancer, the patient should be evaluated for recurrence of cancer and functional change in bowel habits after bowel resection. Evaluation by a gastroenterologist is appropriate to perform a clinical evaluation of the patients symptoms, perform a colonoscopy for colorectal cancer surveillance, and for evaluation of positive fecal immunochemical test results. For these reasons, the request for a referral to a gastroenterologist is medically necessary for evaluation and treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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

The parent of a four-year-old male enrollee has requested for speech and occupational therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that these therapies are well established, with significant peer-reviewed literature to establish both medical necessity and improvement in language and motor skills in children with autism. Early intervention by these therapies, before the age of two and no later than the age of four, is recommended by studies of autistic children.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested equipment that provides continuous passive motion therapy for treatment of her medical condition.   Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the equipment at issue. In this case, the patients provider recommended the use of continuous passive motion therapy in order to prevent hip stiffness. The use of continuous passive motion therapy was indicated to avoid a poor outcome. Therefore, based on the clinical documentation submitted, equipment that provides continuous passive motion therapy is medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the equipment at issue was 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 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 59-year-old male enrollee requested authorization and coverage of 150 catheters a year to assist in urination.  Since his surgery and radiation therapy for cancer approximately four years ago, he has been unable to urinate without a great deal of strain. The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

The enrollee requested authorization and coverage for the medication Verzenio. The enrollee has breast cancer. She had surgery and treatment. There was evidence the disease had spread to her lungs and lymph nodes. The enrollee was started on two medications, but the disease continued to spread. The enrollee will undergo brain radiation therapy. The physician is requesting abemaciclib (Verzenio). The requested medication is in the same category as the one that enrollee is currently taking. Studies do not show this medication works better than the others the enrollee has used.Final Result: Two of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in medical oncology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested speech therapy for treatment of the enrollees autism and speech delay.  The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the requested services. According to Myers and colleagues  People with ASDs have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services. Moreover, speech therapy is recommended for pragmatic language problems in children with ASD. In this case, the patient has pragmatic language deficits as described by the speech therapist. For the reasons stated, speech therapy is medically necessary in this clinical setting.  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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics 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 physical therapy. Findings:  The physician reviewer found that the request for physical therapy is not medically necessary for treatment of the patients medical condition. Physical therapy is a widely used treatment for low back pain. However, the duration and frequency of physical therapy treatments are not adequately addressed in the medical literature. Studies indicate that there is a benefit to therapeutic exercise tailored to the patients condition. In this case, the patients most recent physical therapy note does not have a clear treatment diagnosis or rationale supporting skilled intervention. Based on the clinical documentation submitted for review, additional skilled physical therapy is not medically necessary for 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 physician reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine 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.