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

The patient is a 58-year-old female who suffered a stroke in June 2004 secondary to an intracranial hemorrhage. She received acute rehabilitation and skilled therapy until 9/23/04. Her course was complicated by a gastrointestinal bleed. The patient made some improvements with therapy and was discharged home. She is currently receiving rehabilitation therapy at home. A request has been made for further acute rehabilitation therapy.The patient is receiving an appropriate level of service at home. The role of rehabilitation therapy at home is to teach patients and caregivers. Stroke patients reach maximum recovery approximately three months post stroke with very little gain thereafter. The patients condition is chronic and stable. Although she may make some gains, there is unfortunately no expectation that more intensive rehabilitation therapy will result in clinical improvement. The data and evidence are clear that more intensive rehabilitation therapy does not improve outcomes in severe stroke patients who have stabilized three months post stroke. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a three-year-old female with a history of speech delay who has been receiving speech therapy for articulation problems. The patients developmental pediatrician also documents errors of pragmatic speech, lack of development of age appropriate peer relationships, and lack of social reciprocity. The patient lacks repetitive stereotypical behavior or preoccupation with parts of objects, which is needed for a diagnosis of Asperger's syndrome. A request has been made for reimbursement for speech therapy services the patient received from November 2003 to May 2004. The Health Plan has denied this request indicating the therapy at issue was not medically necessary. The Health Plans denial should be upheld. The patients speech therapist documents the patients primary problem as an issue with articulation. Based upon the information provided, it does not appear the patients speech and articulation errors are aligned with the symptoms associated with the concerns outlined by her developmental pediatrician (i.e., symptoms placing this patient on the autism spectrum). Since the patients primary issues involve articulation, speech therapy was not medically warranted for this patient. Therefore, I have determined that the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Egrifta (tesamorelin for injection) for treatment of his medical condition.   The physian reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. There is a lack of support in the medical literature for the requested medication.  At least two studies have not indicated a change in glucose levels with tesamorelin therapy. There is also a lack of evidence to support that the patients hyperlipidemia or hypertension would be improved. Cardiovascular disease, as measured by coronary artery calcification scores was found to correlate with hepatic fat accumulation in one paper ; but there is a lack of data about the impact of the proposed therapy on cardiovascular disease and outcomes. Moreover, there is a lack of evidence that this therapy would provide significant benefits to the patient. Data from published studies indicate his metabolic conditions would not be improved and there is a lack of evidence regarding long-term cardiovascular disease benefits. For the reasons provided, the request for Egrifta (tesamorelin for injection) is not medically necessary. 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 infectious diseases and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 14-year-old female who was admitted to a residential treatment center on 3/8/04, with the diagnosis of major depressive disorder, recurrent/moderate and oppositional defiant disorder. The patients outpatient psychiatrist also diagnosed the patient with bipolar disorder, which evaluation at the residential treatment center did not confirm. The patients outpatient therapist diagnosed the patient as having conduct disorder. Prior to admission, the patient was apparently abusing alcohol, leaving home, engaging in high-risk situations with sexual acting out, and had poor school performance and attendance. The patient apparently was the victim of a rape approximately ten months prior to admission.Three months prior to admission, it appears the patient superficially cut her arms, which did not require medical attention. The patient denied suicidal ideation at the time of admission and during her stay. She had been treated as an outpatient by two therapists and a psychiatrist but was never treated in a more structured setting such as intensive outpatient or a partial hospitalization program. During her admission, the patient was treated medically with Zoloft 150mg/day with apparent good response.A request has been made for continued residential psychiatric treatment services. The Health Plan has denied the request on the basis that the requested services are not medically necessary.The Health Plans denial should be upheld. The submitted records do not demonstrate that the patient experienced imminent suicidal risk or was a danger to others. In addition, it appears the patient participated appropriately in her treatment during her stay and evidenced no self-destructive behavior or high-risk taking behavior. Furthermore, there is no evidence that as of 3/22/04, the patient was unable to function in meaningful areas of her life. Thus, the submitted evidence does not demonstrate that the patient required the requested level of care after 3/22/04.Based upon the information set forth above, I have determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female enrollee has requested pelvic therapies (pudendal nerve blocks, trigger point injections and physical therapy) provided by a non-plan pelvic pain specialist and a physical therapist for treatment of her pudendal neuralgia. Findings:  The physician reviewer found that there is little controversy as to the benefits of pudendal nerve blocks and physical therapy in the treatment of pelvic neuralgias. The Health Plans contention that there is a lack of scientific evidence is without merit. The literature does support these pelvic therapies and no reasonable alternate treatment was made available to the patient. The providers notes document when and how the patients symptoms started, as well as what circumstances exacerbate or fail to exacerbate the pain. The character of the pain is adequately described along with  associated conditions and past medical/surgical history. It is clear from the record the patient has benefited from these pelvic therapies, and continued treatment is medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld

A 29-year-old male enrollee requested periodontal scaling and root planing (dental procedure code D4342 for teeth numbers 18, 19, 30, 31, 14, 15, 2 and 3) for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the dental necessity of the services. According to the American Academy of Periodontologys Position Paper on the diagnosis of periodontal diseases, initial treatment includes debridement of the plaque/calculus with subsequent re-evaluation to gauge response to this initial therapy. Many patients with no evidence of bone loss or loss of attachment respond favorably to routine debridement and oral prophylaxis. Only after subsequent re-evaluation to gauge response to initial therapy should assessment be made if further treatment such as quadrant scaling and root planing is dentally indicated. In this case, the radiographs document alveolar bone levels near the cementoenamel junction, an indication that this patient has not suffered a loss of periodontal attachment consistent with the periodontal charting of probe depths provided. In addition, the patients provider did not indicate the date of the patients last routine oral prophylaxis. As there is no notation of routine dental care and no evidence of loss of bone or tissue attachment probe depths shown, the scaling and root planning performed was not dentally necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Dupixent. Findings:  The physician reviewer found that U.S. Food and Drug Administration (FDA) approves the use of Dupixent, an interleukin-4 receptor alpha antagonist, for the treatment of patients aged six years and older with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. Boguniewicz and colleagues note that moderate-to-severe atopic dermatitis is defined as involving over 10% of BSA and/or involvement of highly visible areas or those that are important for function such as the hands, neck, face, and genitals, and significantly impaired quality of life. Seigels and colleagues note that the data supporting the safety and efficacy of the use of dupilumab (brand name Dupixent) in moderate-to-severe atopic dermatitis is substantial. Systemic cyclosporine is contraindicated in those with hypertension and kidney impairment, is immunosuppressive and associated with increased infection risk, and is not recommended for younger children. The use of methotrexate, an immunosuppressive, has been associated with increased hospitalization if a patient is infected with COVID-19, and immunosuppressives such as methotrexate, mycophenolate, azathioprine, and cyclosporine may reduce the response to vaccination. In this case, the patient has moderate-severe atopic dermatitis with almost 60% BSA involvement. The patient had tried and failed topical steroids including triamcinolone, mometasone, Clobetasol, and tacrolimus, and was noted has having seen improvement on a trial of Dupixent. Light treatment, which is generally given up to three times weekly, is not an option in this case due to the patients age, as it would require that the patient to miss school, and as the patient does not live near a provider. In this clinical setting, the use of the requested medication is medically indicated. Therefore, Dupixent is 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The mother of an 11-year-old male enrollee requested authorization and coverage of continued pediatric nephrology services for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested services are not medically necessary for management of the enrollees kidney condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested services are medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: At issue is whether the FoundationOne testing panel that was performed was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The patient had a diagnosis of stage three low grade papillary serous ovarian cancer. She presented secondary to a rising CA 125 with suspicion of malignancy.Findings:  One out of three physician reviewers found that there is a lack of evidence that the FoundationOne assay adds to our decision-making ability and yields a result that is clinically beneficial. Finding a mutation does not guarantee that a treatment directed at that mutation will produce a clinically meaningful response. Therefore, the FoundationOne testing panel that was performed was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Two out of three physician reviewers found at the time of request for FoundationOne testing, the patient was undergoing combination therapy for platin-sensitive recurrence but clinically demonstrating lack of significant response, with persistently elevated CA-125 and new complications of extensive peritoneal carcinomatosis.  As a patient with platin-resistant ovarian cancer, the choice of the available standard of care chemotherapies is uncertain. Therefore, the FoundationOne testing panel that was performed was likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the evaluation at issue was likely to have been 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT). IMRT may be considered in the treatment of breast cancer when conventional techniques are inadequate to meet dose volume constraints for critical normal structures. In this case, on review of the medical records, there is no indication that standard dose metrics cannot be met with standard dose planning techniques using 3DCRT treatment planning methods. The routine use of IMRT to deliver adjuvant breast radiation is not supported by guidelines or professional organizations because conventional three-dimensional conformal radiotherapy (3DCRT) or field-in-field techniques are generally able to meet treatment-planning goals. Accordingly, the requested IMRT is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested IMRT is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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: Physician reviewers 1, 2, and 3 are board certified in radiation 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 enrollee requested coverage for the Cosentyx 150mg/ml syringe. The enrollee has a history of severe psoriasis and psoriatic arthritis. The patient has tried and failed topical steroids, UVB (ultraviolet B) phototherapy and Otezla. The patient's dermatologist states that she drinks alcohol and; therefore, disease-modifying antirheumatic drugs (DMARDS) such as Cyclosporine and Acitretin should be avoided. The standard of care currently is to treat both psoriasis and psoriatic arthritis together with the same medication that targets both conditions. Most of the newer systemic medications have been approved by the Food and Drug Administration (FDA) to treat both diseases. Left untreated, psoriatic arthritis can cause pain and disabling joint destruction. Alcohol, even in small quantities, can cause other medications, such as Acitretin, to convert into a substance that remains in the body and is difficult to excrete for over three years. Therefore, Cosentyx is necessary as it does treat both of the patients conditions of severe psoriasis and her psoriatic arthritis.Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cosentyx pen injector. The submitted documentation supports the medical necessity of the requested medication. In this case, the patient has failed treatment with methotrexate, Otezla and Humira.  The medical evidence supports a trial of an interleukin-17 inhibitor like Cosentyx after a failure of methotrexate and a tumor necrosis factor inhibitor. The patient has responded well to this therapy and has no active synovitis or skin lesions. Therefore, Cosentyx pen injector is 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 Harvoni for treatment of his hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials.  For these reasons, the requested Harvoni is 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the sTMS Mini Device for in home use. Findings:  The physician reviewer found that there is sufficient support for the requested device in this clinical setting. The efficacy of single-pulse transcranial magnetic stimulation was demonstrated in a sham-controlled trial by Lipton and colleagues which included 201 adults with episodic migraine with aura. The analysis was based upon 164 patients who treated at least one attack of migraine during the aura phase. The authors noted there were no serious adverse events related to use of the device. Per the medical evidence, transcranial magnetic stimulation should not be used to treat migraine for patients who have epilepsy, since there is theoretical concern that this treatment could trigger seizures. In this patients case, he has a history of chronic migraine. There is no evidence that the patient has a personal history or family history of seizures. Per the records, he has failed first-line migraine therapy. Therefore, the requested sTMS Mini Device for in home use is likely to be superior over other available treatment options.  Final Result: The reviewers determined that the requested device 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: Physician reviewers 1, 2 and 3 are board certified in neurology 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 29-year-old female enrollee has requested duodenal switch procedure for treatment of her obesity.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  The current medical evidence supports the requested duodenal switch procedure in this clinical setting.  This patient has a body mass index of 44 with multiple weight-related comorbid conditions.  She has failed dietary efforts in the past and has completed a multidisciplinary evaluation that did not reveal any obvious dietary, behavioral, or medical barriers to surgery.  The duodenal switch procedure is a standard primary treatment for morbid obesity.  All told, the requested duodenal switch procedure is medically indicated for the treatment of this patient.