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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee requested speech therapy three times per week for treatment of the enrollees language impairment and autism spectrum disorder.  Findings:  The physician reviewer found that the medical literature states that most children with autism spectrum disorder receive speech services in the preschool and elementary school years but typically by middle school speech services have been replaced by resource room supports. In addition, the medical literature indicated that speech and language therapy did provide improvements in communication skills and social skills, but no improvements on standardized testing.  In this case, the patient presents with autism spectrum disorder and additional speech language impairments. Some of his speech deficits are related to autism spectrum disorder such as abnormal prosody and asking questions rather than stating what he wants. In addition, some of his speech deficits are receptive and expressive language delays. Thus, speech therapy is clinically indicated for this patient. However, per the progress notes the patient missed several of his visits, which may impact his rate of progress. Given that the patient has missed several of his visits, increasing his speech therapy to two times per week is medically necessary and appropriate in this clinical setting.Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a labiaplasty for treatment of her medical condition.  Findings:  The physician reviewer found that there is sufficient support in the medical literature for the requested services in this clinical setting. Rouzier and colleagues reviewed the records of 163 patients and found that the motives for requesting surgery were aesthetic concerns in 87% of the cases, discomfort in clothing in 64%, discomfort with exercise in 26%, and entry dyspareunia in 43%. In this case, the patient has a functional impairment. She complains of dyspareunia, pain with activity and pain with wearing clothes. The physical examination documents the abnormality. The patient has functional concerns, and cosmetic concerns do not appear present for this patient. Based on the medical documentation submitted for review labiaplasty is medically necessary for treatment of the patients medical condition. 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 plastic 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: Upheld

The parent of a six-year-old female enrollee has requested applied behavioral analysis (ABA) therapy (20 to 40 hours per week for treatment of the enrollees Landau-Kleffner Syndrome.  Findings:  Three physician reviewers found that ABA is an experimental and investigational treatment for patients with Landau Kleffner Syndrome. A review of the relevant medical literature failed to yield documentation of controlled trials supporting the efficacy of ABA therapy in the treatment of Landau-Kleffner Syndrome. Additional long-term clinical study is needed before ABA therapy can be recommended for this diagnosis.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a 12-week course of Harvoni for treatment of his hepatitis C.  Findings:  The physician reviewer found that the current medical evidence supports the requested medication in this clinical setting.  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 for 12 weeks.  All told, the requested 12-week course of Harvoni is medically indicated 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 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

The mother of a 15-year-old female enrollee requested authorization and coverage of continuous use of the Ortho Evra patch for one year. The Health Plan denied the request indicating that the requested prescription is not medically necessary for treatment of the enrollees pelvic and ovarian pain. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested prescription is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential level of care services for treatment of the enrollees behavioral health condition. Findings: The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue. According to the documentation submitted for review, the patient was experiencing mild to moderate post-acute withdrawal syndrome (PAWS). The patient was not a danger to themselves or to others. The patient did not have emotional, behavioral, cognitive, or impulsive symptoms that would warrant residential level of care. The patient was motivated and appeared to be working with the treatment program. The patient was medically and psychiatrically stable. She had support systems in place. Although she continued to struggle with her emotions and required further treatment to help develop her coping skills, the structured environment of residential treatment was no longer medically necessary. The patient could have continued treatment at a lower level of care. Therefore, the residential level of care services have not been established as medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Zepatier 50-100 mg tablets for 12 weeks. Findings:  The physician reviewer found that according to the 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 should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1b patients should be treated with regimens including Zepatier for 12 weeks, based on clinical trial results showing a 99% cure rate regardless of nonstructural protein 5A resistance. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with  Zepatier 50-100 mg for 12 week to treat hepatitis C is supported as medically necessary. 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 the central auditory processing disorder (CAPD) test for evaluation of his behavioral health condition. The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. In general, central auditory processing refers to several systems involved in both verbal and nonverbal communication. Since there are multiple proposed mechanisms, the term central auditory processing disorder (CAPD) is rather non-specific with regard to etiology. There is a lack of adequately-powered, well-designed studies demonstrating the usefulness of testing. Carpenter and colleagues recommended additional research investigating the clinical utility of [central auditory processing] testing for individuals with autism spectrum disorder. However, testing is not part of routine assessment for autism spectrum disorder. In this case, the patient is receiving comprehensive, clinically appropriate care for his medical conditions. These services include speech therapy which represents a reasonable intervention aimed at compensating his language and communication deficits. Since the clinical value of CAPD testing for adults is not established in the peer-reviewed medical literature, and in the absence of recommendation for testing by his treatment team, the requested services are not medically necessary for evaluation of the patients medical condition. 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.  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: Experimental/Investigational
Decision: Overturned

A 59-year-old male enrollee requested transcranial magnetic stimulation for medical treatment of his major depressive disorder.  Findings:  Two physician reviewers found that in this patients case, the requested services are likely to be superior over other treatment options.  He has already undergone antidepressant treatment with maximum dosages for adequate periods of time with antidepressants of several different mechanisms.  The patient has had augmentation with Abilify and lithium.  The patient has undergone treatment with cognitive therapy and electroconvulsive therapy.  There is sufficient support for transcranial magnetic stimulation in this clinical setting.  All told, transcranial magnetic stimulation is likely to be of greater benefit than other alternatives.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 44-year-old female who has a history of recurrent low back pain with radiation down to the bilateral posterior calves. An MRI revealed degenerative disc disease and lumbar facet disease. Upon examination, the patients provider noted straight leg raising was negative and deep tendon reflexes were normal and equal throughout. In addition, sensation and strength were grossly normal. The patient has requested authorization for a wheelchair. The Health Plan has denied the request on the basis that a wheelchair is not medically necessary for the patients mobility.Review of the submitted medical records does not demonstrate that a wheelchair is medically necessary for this patient. The patient has been noted to be ambulatory without assistive devices. Additionally, the documented evidence indicates her gait is nonantalgic and strength is intact. In fact, upon examination by the patients provider, it was noted the patient was able to heel-toe walk without any difficulty. Thus, there is no evidence that the patient is unable to ambulate requiring a wheelchair for mobility. Therefore, I have determined that the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus (HCV). Findings: The physician reviewer found that per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment guidelines, there is only one treatment option for this patient in whom previous sofosbuvir plus ribavirin with or without peginterferon treatment has failed, and has no cirrhosis. Daily fixed-dose combination of ledipavir (90 mg)/sofosbuvir (400 mg) with weight-based ribavirin for 12 weeks is recommended for patients without cirrhosis is recommended as a Class IIb, Level C rating. AASLD/IDSA states To date, clinical experience and trial data on the retreatment of such patients are very limited. However, retreatment after a sofosbuvir-containing treatment failure with a second course of treatment using sofosbuvir plus new agents, or retreatment with the same sofosbuvir-based regimen has been reported. There is insufficient data available at this time regarding the treatment of Technivie in this patients clinical setting. Retreatment with ledipasvir/sofosbuvir in patients with HCV genotype 1 infection, with or without cirrhosis, in whom a sofosbuvir-containing regimen failed, has been evaluated in two small pilot studies utilizing ledipasvir/sofosbuvir for 12 weeks. With prior failures of 24 weeks of sofosbuvir plus ribavirin, high sustained virologic response (SVR) rates were noted when patients were retreated with ledipasvir/sofosbuvir for 12 weeks. (Osinusi, et al) Ledipasvir/sofosbuvir plus ribavirin has also been evaluated in subjects in whom prior treatment with sofosbuvir plus peginterferon and ribavirin or sofosbuvir and ribavirin failed. In this study of 51 patients, retreatment with ledipasvir/sofosbuvir plus ribavirin for 12 weeks led to SVR at 12 weeks in 100% of 50 patients with HCV genotype 1 infection; 1 virologic failure was observed in a patient determined to have HCV genotype 3 infection prior to retreatment (Wyles, et al). As such, the medical necessity for Harvoni has been established in this clinical setting.  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 physician 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for occipital nerve stimulation for treatment of the enrollees headaches.Findings:  Three physician reviewers found that There is a lack of large, rigorous, randomized and sham controlled trials to support the superior effectiveness of the requested services in this clinical setting. This patient has a headache history consistent with chronic migraine. She has tried several oral preventives, and one cycle of Botox. Nerve blocks have given her transient relief. However, the medical evidence regarding occipital nerve stimulation for chronic headache is very mixed. This patients history is not typical of occipital neuralgia, but rather, of chronic migraine. Moreover, there is documentation in the headache clinic notes reporting that not all oral medications have been tried and that there could be a reasonable probability of benefit. In addition, she has not had an adequate trial with Botox, which by the clinical evidence has the greatest likelihood of success for management of chronic migraine. A recent review of interventions for chronic headache by Ambrosini and Schoenen notes there is clear evidence for a preventative effect of suboccipital injections of local anesthetics and/or steroids in cluster headache, while evidence for such an effect is weak in migraine.  For the reasons noted above, occipital nerve stimulation is not likely to be superior to other therapies available for treatment of this patient.  Final Result: The three reviewers determined that the requested procedure 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: All three physician reviewers 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a full hospital admission and stay, post gallbladder surgery. Bagla and colleagues note that cholecystectomy remains the only definitive therapy for acute cholecystitis and that current guidelines recommend treatment on the basis of disease severity at presentation. Thangavelu and colleagues note that management of acute cholecystitis by emergency physicians should be made based on patient's clinical status. In this case, the patient presented with acute pain for five days, and required extended evaluation with a HIDA scan that suggested acute cholecystitis for which he was treated surgically. The patient had a drain placed during surgery, was monitored for evidence of bleeding, and continued on intravenous pain medication. One day postoperatively, the patient appeared stable, was started on a regular diet, transitioned to oral pain medications, had his drain removed, and was discharged to his home. In this clinical setting, acute inpatient admission for the evaluation, treatment, and postoperative care of acute cholecystitis was medically indicated. Therefore, the full hospital admission and stay, post gallbladder surgery, was medically necessary for the treatment of this patient. 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 surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested retroactive authorization and coverage for monitored anesthesia care endoscopic gastrointestinal procedures for treatment of the enrollee, who has a history of intolerance to narcotics and severe anxiety.  Findings: The physician reviewer found that there is sufficient support for the services at issue in this clinical setting.  Monitored anesthesia care is warranted in patients with psychological impediments to cooperation (such as severe anxiety in this case), as well as patients undergoing long procedures, such as combined endoscopy and colonoscopy.  Endoscopy can be performed using conscious sedation with a benzodiazepine and opioid.  Per the medical evidence, when a benzodiazepine and opioid may not be effective, as in this patient with reported opioid intolerance, other agents such as propofol may need to be used.  All told, monitored anesthesia care was medically indicated for the treatment of this patient.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 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: Upheld

A 44-year-old female enrollee requested a water circulating cold pack with pump for medical treatment of her medical condition.  Findings:  Three physician reviewers found that in this patients case, the use of water circulating pump was not likely to have been more beneficial than simpler applications.  While the use of cryotherapy may have been beneficial, simpler applications of cold have been demonstrated to be equally efficacious.  Thus, the use of a water circulating cold pack with pump was not likely to be more effective than other options.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year male enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that research shows the children with developmental apraxia of speech have more success when they receive frequent (3-5 times per week) and intensive treatment. Children seen alone for treatment tend to do better than children seen in groups. However, as the patient improves, they may need treatment less often, and group therapy may be a better alternative. Consistent with the evidence based treatment interventions for speech delay, the requested speech therapy is medically necessary for this patient and should be provided for a minimum of five hours per week. In addition, the patient should undergo a thorough speech and language evaluation and complete work-up to look for possible etiology of the speech delay.