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

The parent of a five-year-old male enrollee has requested one-to-one speech therapy three times per week for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that speech-language pathologists use different approaches to treat apraxia of speech, and no single approach has been proven to be the most effective. Therapy is tailored to the individual and is designed to treat other speech or language problems that may occur together with apraxia. Each patient responds differently to therapy, and patients with apraxia of speech usually need frequent and intensive one-on-one therapy. Support and encouragement from family members and friends are also important. Therefore, the requested speech therapy has been demonstrated to be medically necessary for treatment of this patients medical condition. These services should be provided at a minimum of 60 minutes for 3 days per week until such time that the treating speech therapist does not document any improvements in goals for at least an 8-week period.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Perjeta (J9306) 420 units every 21 days for treatment of the enrollees triple positive invasive ductal carcinoma of the breast. Findings:  Three physician reviewers found that Perjeta is an antibody directed against the cluster of HER genes, which are overexpressed in HER2 positive breast cancer. Though similar to Herceptin, its activity is different, leading to interest in the combination of Perjeta with Herceptin. Randomized studies have shown that using the combination of antibodies, along with chemotherapy, is superior in outcome to using only Herceptin, in patients with metastatic breast cancer. The National Comprehensive Cancer Network (NCCN) indicates that the combination of the antibodies, along with chemotherapy, has become standard of care in the neoadjuvant situation. However, the remaining issue is whether a patient should be treated with the combination of antibodies, as opposed to Herceptin alone, in the adjuvant situation, as in this patients clinical situation. Overall, there is a lack of data to demonstrate that adding Perjeta to Herceptin in the adjuvant situation provides additional clinical benefit. Until such convincing data becomes available, there is no proven clinical benefit from adding Perjeta to Herceptin in adjuvant therapy. Final Result: The reviewers determined that requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: Reviewers 1, 2, and 3 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 spouse of a 65-year-old male enrollee has requested continued stay at a skilled nursing facility (SNF) level of care for the treatment of the enrollees medical condition. Findings:  The physician reviewer found that this patient required and continues to require the services of a skilled physical and occupational therapist to maintain and advance his functional status as he recovers from a ruptured Achilles Tendon and scapular fracture. These treatments could not be provided by alternative unskilled providers, and therefore are medically necessary. Skilled therapy services are needed on a daily basis, and given the extent of his impairments and the presence of multiple co-morbidities, these services are most appropriately provided in an inpatient setting.
Appeal type: Medical Necessity
Decision: Upheld

Standard ReviewA transgender female enrollee has requested authorization and coverage for consultation, voice evaluation and laryngoscopy for feminizing voice training. The Health Plan has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees gender dysphoria.  Credentials/Qualifications: The reviewer is board certified in otolaryngology 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. Nature of Statutory Criteria/Case Summary: The documentation provided does not support the medical necessity for the requested services in this clinical setting. There is evidence in the medical literature to support voice training in female transgender individuals to alleviate dysphoria that may interfere with their ability to communicate with others. The literature also shows that voice resonance drops in puberty after exposure to testosterone and that estrogen replacement therapy may not reverse that change. However, while it was noted in the Independent Medical Review application that this patient experienced being misgendered, documentation in the clinical reports are lacking to support that her symptoms of gender dysphoria have been exacerbated due to her low pitch voice. A provider noted that the patient was interested in vocal training.  At her next visit with the provider, the clinical notes indicated that the patient was stable on current doses for hormone therapy. Also at this visit, the provider prescribed progesterone at 100 mg dosing. On the other hand, there was no documentation provided as to how this patients voice affected the status of her gender dysphoria. At a later visit, the patient was seen for symptoms with cough. The clinical notes involving her gender dysphoria treatment included an increase of estradiol to 8 mg with testosterone fully suppressed. However, there was a lack of documentation as to voice feminization therapy. While the studies may show that there are female transgender individuals who are fearful of speaking because of the male resonance quality of the voice, this has not been noted in the submitted clinical documentation for this patient. As such, the documentation provided does not support the medical necessity for the requested services. For these reasons, the requested consultation, voice evaluation and laryngoscopy for feminizing voice training are not medically necessary for the evaluation of this patients gender dysphoria. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for myRisk hereditary cancer genetic testing performed by Myriad Genetics Laboratories, Inc. This patient was diagnosed with breast cancer and she has an extensive family history of cancer. Current data suggest that several cancer syndromes, including hereditary breast and ovarian cancers, are indications for genetic testing. Testing to isolate high-risk gene mutations in families has improved the outcomes of genetic counseling, surveillance, and prophylactic treatment measures. Evolving research has demonstrated that in addition to high-risk genes, other genes contribute to the familial cancer predisposition, which lends support for the clinical utility of gene panels such as the myRisk hereditary cancer genetic testing. Gene panel testing offers a reliable and expedited approach for the diagnosis for heritable cancer syndromes. Therefore, the myRisk hereditary cancer genetic testing performed by Myriad Genetics Laboratories, Inc. was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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: Physician reviewers 1, 2, and 3 are board certified in genetics 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

A 63-year-old male enrollee requested substance abuse residential treatment services for medical treatment of his behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  Per the medical records, the treatment provided was for active treatment and was reasonably expected to improve his condition and prevent a more serious episode of illness.  Further, the duration of services was consistent with community practice standards.  Considering the clinical presentation and the peer-reviewed literature, substance abuse residential treatment services were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested orthoptic training for treatment of the enrollees convergence insufficiency. The physician review found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the services at issue. Convergence insufficiency is under the broad category of vergence dysfunction. Evidence-based research demonstrates that orthoptic training has a high success rate in the treatment and management of vergence dysfunction. Office-based orthoptic training has been shown to have the greatest impact on improving the fusional ranges of patients with convergence insufficiency. In-office therapy has also been shown to be more effective than either prescribed computerized home therapy or pencil push-ups alone. For these reasons, orthoptic training was medically necessary for the treatment and management of the patients convergence insufficiency. 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 optometry 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 53-year-old female enrollee has requested Orthovisc injections for treatment of her osteoarthritis.  Findings:  Three physician reviewers found that the requested Orthovisc injections are not likely to be of greater benefit than other treatment options in this clinical setting.  This patient has right knee osteoarthritis.  Her prior treatment has included two series of viscosupplementation therapy.  Per the current medical literature, more than two series of injections have not been proven efficacious.  In sum, there is a lack of support for the requested services for the treatment of this patient
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 59-year-old male with idiopathic pulmonary fibrosis (IPF). According to an initial consultation with his pulmonologist, the patient has a medical history of diabetes mellitus, coronary artery disease, and is status post coronary artery bypass graft. At this consultation, the patient presented with progressive shortness of breath, non-productive cough and abnormal chest radiograph. The patient was previously hospitalized twice for pneumonia. Spirometry showed FVC 71%, FEV1 82%, and FEV1/FVC 92%. On 2/4/04, a CT scan of the chest revealed bilateral interstitial fibrosis primarily at the bases and periphery. Results of bronchial washings and transbronchial biopsy performed on 2/13/04 were non-diagnostic. On 3/1/04, an open lung biopsy revealed unusual interstitial pneumonitis. Based upon negative workup looking for infectious and malignant etiologies, the patient was diagnosed with IPF. Thereafter, additional pulmonary function tests revealed a decline with an FVC of 59% and an FEV1 of 59%. Clinically the patient had worsening shortness of breath and was placed on supplemental oxygen. The patient has been treated with varying doses of prednisone with limited efficacy. The patient did not tolerate azathioprine. The patients provider has requested authorization for Actimmune (interferon gamma-1b). The Health Plan has denied this request. The study by Ziesche, et al. enrolled 18 patients and studied the effects on Actimmune in the treatment of IPF. The results showed statistically significant improvement in total lung capacity, forced vital capacity and paO2 in patients treated with thrice weekly Actimmune. The results were promising and have led to a phase III trial using Actimmune versus placebo in the treatment of IPF. Kalra, et al. concluded Actimmune did not benefit IPF patients. Davies, et al. found little evidence to support the use of Actimmune in the treatment of IPF. Honore, et al. found that Actimmune can cause respiratory failure in IPF patients. Raghu, et al. reported in a prospective, double-blind study of 330 patients with IPF that treatment with Actimmune did not affect progression-free survival, pulmonary function or quality of life. The Raghu study appears to be the most comprehensive and clinically relevant study of the role of Actimmune in the treatment of IPF. Because a number of studies have found no benefit and some evidence of harm, Actimmune cannot be recommended for this patient. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old female enrollee has requested lap-band surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient has a BMI of 42.2 and multiple co-morbid conditions, therefore, she meets the National Institutes of Health (NIH) criteria for bariatric surgery. The Health Plan indicates that the patient must obtain a presurgical weight of 253 pounds before surgery can be approved. Sjostrom and colleagues conducted a study demonstrating that surgical weight loss procedures are the only real alternative for treatment of morbid obesity. There is no scientific data to support delayed surgical intervention in this setting. In the case of this patient, she is seeking authorization for the lap-band procedure. The medical literature has consistently shown the lap-band is efficacious and is associated with less morbidity than other weight loss procedures. The lap-band procedure offers the potential for significant weight loss and is medically appropriate for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested substance abuse residential treatment center level of care for medical treatment of his substance abuse.  Findings:  The physician reviewer found that the records indicate that this patient was not in withdrawals, and was not at risk for imminent withdrawals on admission or during the treatment period under review. There was no suicidal, homicidal, or psychotic ideation and no self-harm behavior. In addition, the patient was medically and psychiatrically stable such that medication changes could have been achieved at a lower level of care. He was cooperative and participated in his treatment plan. There was no evidence that 24-hour supervised care was required to prevent decompensation. Treatment could have been safely and adequately provided at a lower level of care along with community support such as a 12-step group with a sponsor. Consistent with these findings, substance abuse residential treatment center level of care was not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old female enrollee requested lab testing for medical evaluation of her Crohns disease.  Findings:  Two physician reviewers found that in this patients specific case, her clinical presentation prior to undergoing Anser IFX testing suggested therapeutic infliximab response had already been achieved. Therefore, the Anser IFX testing was not performed for a specific indication. Also, available records do not support that the Anser IFX had any immediate impact on her health outcome. For these reasons, lab testing was not likely to have been more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for treatment with a neuromuscular specialist, electromyography (EMG) and nerve conduction study. Neuromuscular disorder is a broad term that refers to diseases that affect the nerves that control the muscles. There are a number of pathologies that fall within this term.  Weakness, muscle twitching and stiffness are common complaints that may or may not be associated with neuromuscular pathology. Evaluation of patients with these complaints encompasses a thorough history, physical examination, neurological imaging, neurophysiologic evaluation, and serum testing. Per the submitted documentation, this patient has undergone evaluation by multiple neuromuscular specialists. During his work-up, he underwent imaging, serum laboratory testing, and neurophysiologic testing which have been reported as unremarkable. The medical evidence does not support the requested services in this clinical setting. There is a lack of support for additional evaluation with EMG or nerve conduction study in this patients case. Additionally, the records do not support treatment with a neuromuscular specialist in this setting. Therefore, treatment with a neuromuscular specialist, EMG and nerve conduction study are not medically necessary for the evaluation and treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation and 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Hysingla ER 80 mg for treatment of the enrollees chronic pain syndrome. Findings: The physician reviewer found that Hysingla is an opioid analgesic recommended after a trial of a first-line oral analgesic has failed. Opioids are generally not recommended as first-line therapy but, when used, providers should closely monitor patients for loss of response, adverse effects or aberrant behavior, and revise the treatment plan accordingly. In this case, the records do not document that the use of the prescribed opioid medication decreased the patients level of pain from one visit to the next. In addition, there was no noted functional improvement or improved pain noted during the duration of the prescription. 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 with sub-specialty certification in pain 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 38-year-old female enrollee has requested autonomic nerve function testing for treatment of her medical condition. Findings:  Three physician reviewers found the autonomic nerve function testing was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Autonomic neuropathy symptoms and signs include unreactive pupils, orthostatic hypotension, and bowel and bladder issues. The patients provider diagnosed the patient has anxiety, MVP and insomnia with no indication of neuropathic symptoms. Moreover, the records do not evidence the patient has a history suggestive of neuropathy, specifically autonomic neuropathy. In sum, the services at issue were not likely to be more beneficial than standard testing for the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old female has requested Aciphex 20mg (1 per day) for the treatment of her gastroesophageal reflux disease. Findings:  The physician reviewer found that the relationship between acid reflux and dental erosions remains the subject of debate. Many patients with documented acid reflux do not have dental abnormalities such as erosions or periodontal disease. If there is a connection in this patients case, Nexium (one of the Health Plans formulary alternatives) is appropriate to prevent this problem. Its ability to heal erosive esophagitis and other complications of gastroesophageal reflux disease is superior to other PPIs. As such, the alternative medication offered by the Health Plan is medically reasonable and appropriate in this setting. The medical necessity of Aciphex 20mg (1 per day) has not been established.