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

The patient is a 47-year-old female who developed a hematoma after a blood draw from the left antecubital region resulting in pain. She has continued arm pain. The physical therapy records provided show the patient had 44 visits. She has requested authorization for continued physical therapy. The Health Plan has denied this request indicating the requested therapy is not medically necessary.Review of the submitted physical therapy notes reveals the patients physical therapist instructed the patient in a full home-exercise program involving range of motion and strengthening exercises. The patient was discharged from physical therapy in December 2004 with goals reached. At that time, her range of motion was 150 degrees in flexion and 110 degrees in abduction. Based upon the documentation provided, the patient should be able to continue with her home program independently. 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: Overturned

A 53-year-old female enrollee has requested Baraclude (entecavir) 0.5 mg tablet for treatment of her hepatitis B virus.  Findings:  The physician reviewer found that Tenney and colleagues reported results for over five years of therapy showed that in nucleoside-naive patients, the cumulative probability of genotypic entecavir resistance (ETVr) and genotypic ETVr associated with virologic breakthrough was 1.2% and 0.8%, respectively. The authors concluded that Long-term monitoring showed low rates of resistance in nucleoside-naive patients during 5 years of [entecavir] ETV therapy, corresponding with potent viral suppression and a high genetic barrier to resistance. These findings support [entecavir] ETV as a primary therapy that enables prolonged treatment with potent viral suppression and minimal resistance. Although the goal of treatment end-point of therapy for patients with hepatitis B e antigen (HBeAg)-positive chronic hepatitis B includes HBeAg seroconversion, the HBeAg seroconversion rate seen in clinical settings for oral nucleosides appears much lower than  the 15% to 22% after one year of oral nucleosides reported in pivotal trials (Lin, et al). Lin and colleagues study concluded that, HBeAg-positive patients should be counseled about the high possibility of the long treatment duration required to achieve recommended treatment end-points. Accordingly, Bang and Kim note The correct choice of a first-line treatment of high potency and with a high genetic barrier to achieve sustained long-term suppression of viral replication provides the best chance of preventing treatment failure and the emergence of drug resistance. This is the providers intention with the recommendation for continuing Baraclude for this patient. Therefore, the medical necessity of the requested medication has been established in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for testosterone cypionate injections Findings: One study noted that, The aim of testosterone replacement therapy (TRT) is to improve symptoms and signs of testosterone deficiency including decreased libido, erectile dysfunction, depressed mood, anaemia, loss of muscle and bone mass, by increasing serum testosterone levels to physiologic range. Testosterone replacement therapy for hypogonadotropic hypogonadism is based upon laboratory documentation of below normal values on two serum testosterone levels drawn in the morning at least 24 hours apart. In patients receiving ongoing therapy, a pre-injection morning value in the low to low-to-normal range is also a clinical indication for continuation of therapy. However, this patients records do not include report of two testosterone levels in the morning at least 24 hours apart. The current medical literature supports holding therapy to obtain supportive laboratory values to establish whether the patient meets the requirements for treatment. Based on the documentation provided for review, the requested testosterone cypionate injections are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in urology 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

This patient is a 59-year-old male who underwent knee arthroscopy and microfracture surgery in June 2006. The patients treating surgeon recommended the patient utilize a continuous passive motion (CPM) device for eight weeks post-operatively. The reason for recommending the CPM device was to assist the patient in achieving maximum benefit from the surgery and optimal results. The Health Plan has denied authorization for the CPM device.The patient underwent surgery to regenerate cartilage to a portion of his knee that had lost articular cartilage. Post-operative CPM is utilized to maximize the benefits of the procedure. It is standard within the California orthopedic community to recommend CPM for patients such as this patient. CPM is not considered experimental for this patients condition and is medically indicated for this patients condition. Therefore, I have determined the requested equipment is medically necessary. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a five-year-old female enrollee has requested PediaSure for treatment of the enrollees short stature.  Findings:  The physician reviewer found that a childs growth must be assessed over multiple visits over time to determine any growth abnormalities. Definition of short stature when not attributed to an underlying organic disease is classified as familial short stature, constitutional short stature or idiopathic short stature (ISS). Children with familial short stature have a bone age corresponding to chronologic age and height standard deviation which also corresponds to parental height standard deviation. Those with constitutional short stature have a bone age corresponding to adjusted height age and will have a normal adult prognosis. Children with ISS have a negative two standard deviation for bone age and for mean parental height. These children are candidates for growth hormone. According to Rosenbloom, normal short stature does not require treatment for physical health benefits. This patient has been shown to have no deficiency at this time other than short stature with bone age equaling adjusted height age which indicates that she has constitutional short stature. This does not lead to nutritional deficiencies and therefore, a nutritional supplement is not needed. The patients labs also demonstrated that she is not anemic. Therefore, there is no medical justification for a nutritional supplement at this time.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that in order to objectively determine if the patient meets criteria for length of stay, the Level of Care Utilization System (LOCUS) criteria will be applied. This is an accepted, national standard for determining the appropriate level of care for adults. With regards to risk of harm, the records support a score of 2.  There was no documentation of prior suicide attempts, and the patient did not have suicidal ideation.  In terms of functional status, the records support a score of 3.  The patient had moderate impairment and had significant deterioration in his ability to fulfill his responsibilities. With regards to medical/addictive/psychiatric comorbidity, the records support a score of 3. The patient has alcohol use disorder and marijuana use disorder. The patient has also been diagnosed with reactive attachment disorder.  His recent substance use has had detrimental effects to the patient. With regards to recovery environment, the records support a score of 3.  The patient reported interpersonal conflicts with his mother. In terms of level of support, the records support a score of 2.  The patients father was supportive of the patient and would be likely be willing to participate in treatment if asked to do so. With regards to response to treatment and recovery, the records support a score of 3. The patient had partial recovery for moderate periods of time with strong professional help. In terms of engagement and recovery status, the records support a score of 3.  The patient had limited engagement and recovery.  He is ambivalent about changing. He was passively engaging in treatment. Thus, the records support a total score of 19. Based on these criteria, the patient would meet criteria for an intensive outpatient program. Therefore, residential treatment center services provided were not medically necessary for the treatment of this patient. 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: The patient has requested authorization and coverage for intravenous immunoglobulin (IVIG) Octagam 40 gm daily x four days, then 40 gm daily for two days every four weeks for 12 weeks. Findings:  The physician reviewer found that Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a chronic progressive or relapsing and remitting disease that can cause weakness and sensory loss. CIDP tend to respond well to therapies that reduce inflammation. As noted by Oaklander and colleagues, IVIG and corticosteroids remain first-line treatments for patients with CIDP. According to the Evidence-based Guideline by the American Academy of Neurology (AAN), IVIG is effective and should be provided in the long-term care of patients with CIDP (Patwa, et al.). The European Federation of Neurological Societies (EFNS) and Peripheral Nerve Society (PNS) have identified pure sensory CIDP, or chronic immune sensory polyradiculopathy (CISP), as a condition that presents with sensory neuropathy, ataxia, and normal nerve conduction from selective sensory nerve root inflammatory demyelination (Doneddu, et al.). According to the EFNS/PNS, IVIG therapy has been found to be safe and effective in the treatment of patients with CISP as well as in patients with typical CIDP. In this case, the patients condition is consistent with progressively worsening CISP. The records document that the patient is experiencing symptoms that are interfering with her ability to perform activities of daily living. Based on the AAN guidelines and current medical literature, the planned regimen of IVIG is supported as appropriate for treatment of this patients CISP. Therefore, the requested IVIG Octagam 40 gm daily x four days, then 40 gm daily for two days every four weeks for 12 weeks is medically necessary for 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 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: Experimental/Investigational
Decision: Upheld

A 50-year-old male enrollee requested authorization and coverage of participation in a clinical trial using iodine-131 labeled MIBG for the treatment of metastatic paraganglioma.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that participation in a clinical trial using iodine-131 labeled MIBG  is not likely to be more beneficial for treatment of the enrollees metastatic paraganglioma than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 44-year-old female who presented to her primary care providers in January 2005 with a diagnosis of infertility. A referral in September 2005 to the Health Plan infertility clinic was made. A hysterosalpingogram was ordered and performed, and was normal. Serum FSH levels were drawn twice, one week apart, and were in the normal range (less than 5 mlU/ml). The patient requested donor intrauterine insemination (IUI). Subsequent visits revealed that the patient was told that further treatment with IUI was not indicated, and that the pregnancy rates were 0% because of her age and obesity. She was advised to pursue in vitro fertilization treatments with donor eggs. The patient has requested coverage for IUI which the Health Plan has denied based upon a determination that it is not medically necessary.This patient has the diagnosis of age related infertility. Women over the age of 40 have a dramatically reduced chance for either spontaneous or treatment pregnancy due to ovarian resistance. However, spontaneous and treatment pregnancies are possible. The overall pregnancy rate for either in vitro fertilization (IVF) using the patients eggs, or IUI, in this age group is less than 5%. In the case of this patient, FSH levels were in the normal range. This reflects the possibility of pregnancy with treatment, as compared to an elevated FSH that would prove severe ovarian resistance beyond the age itself, and offer little to no chance for treatment success. The Health Plans committee states that the better treatment option is egg donation and this is in agreement with an ASRM Committee Opinion. However, this is only partially true. While the Committee Opinion supports the option of egg donation, it also lists controlled ovarian hyperstimulation with IUI as an alternative. The patient is seeking appropriate alternative care that has the potential to result in pregnancy. As such, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Afinitor 2.5 mg tablets and/or Imbruvica 140 mg capsules. Findings:  The physician reviewer found that records provided for review document that this patient presents with stage IV glioblastoma status post subtotal resection. The patients provider has recommended treatment with a combination of Afinitor and Imbruvica. The U.S. Food and Drug Administration (FDA) has not approved Afinitor or Imbruvica for the treatment of patients with glioblastoma. In addition, this medication regimen is not supported by major drug compendia or the National Comprehensive Cancer Network (NCCN) guidelines. Moreover, the requested medication combination is not supported by the medical literature for use in this patients clinical scenario. Given these findings, the requested Afinitor 2.5 mg tablets and/or Imbruvica 140 mg capsules are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication regimen 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 subspecialty certifications in medical oncology and hematology 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 60-year-old male enrollee has requested Xifaxan for the treatment of his Crohns disease. Findings:  The physician reviewer found that the use of Xifaxan is not medically necessary in the treatment of Crohns disease. The use of this medication is typically in a setting of Travelers diarrhea, hepatic encephalopathy or bacterial overgrowth in small intestine. Its use in Crohns disease is limited and not FDA approved. A search of the medical literature revealed little data regarding the efficacy of Xifaxan in this context. A study by Prantera, et al. looked at this issue, but the difference between the treatment group and placebo was not statistically significant. There is inadequate evidence-based support for the use of Xifaxan in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C 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 guidelines, treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Per AASLD guidelines, renal impairment does not require modification of therapy if creatinine clearance is over 30 mL/min.  AASLD guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a two-year-old female enrollee has requested authorization and coverage for occupational therapy, feeding therapy and physical therapy. Findings:  The physician reviewer found that the request for occupational therapy, feeding therapy and physical therapy are medically necessary for the treatment of the patients medical condition. There is sufficient medical literature supporting the requested services in this clinical setting. According to studies, Current conventional treatment of autism spectrum disorder (ASD) in children includes intensive behavioral interventions (known as applied behavioral analysis or ABA), rehabilitative services such as speech therapy, occupational therapy, physical therapy, social skills training, and counseling. Studies find that for children with autism spectrum disorder, Goals should include improved functional verbal and nonverbal communication and social skills, increased engagement in developmentally appropriate activities, improved fine and gross motor skills, and the development of independent academic and organizations skills, as well as replacement of problem behaviors with developmentally appropriate behaviors. In addition, studies describe the importance of feeding therapy in children with autism spectrum disorder. Affected children often have severely restrictive diets. Given the support cited above, the request for occupational therapy, feeding therapy and physical therapy are medically necessary for treatment of the patients moderate-to-severe autism spectrum disorder. 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 and neurology with special qualification in child 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: Overturned

The parent of a 14-year-old female enrollee has requested residential treatment care for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that this patient is a very young patient with severe behavioral health issues. Based on the evidence provided, she was out of control emotionally, which could signal a mood disorder. In addition, she has an eating disorder and also has significant family conflict. Because of this patients extreme behavioral health issues, she required treatment in a 24-hour setting during the period at issue. She could not have been safely treated in a less intensive environment. Her methods for acting-out were potentially very harmful, if not fatal. In light of the severity of the patients symptoms, residential treatment level of care was medically necessary during the time period at issue.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 72-year-old man with a history of back pain and sciatic pain. The patient has apparently been unable to tolerate physical therapy except for aquatic therapy, which he reports has been very effective. The patient has requested authorization and coverage for aquatic therapy. The Health Plan had denied the request on the basis that aquatic therapy is not medically necessary.Review of the relevant medical literature suggests that aquatic therapy is at least as efficacious as land-based therapy. A randomized, controlled study showed the efficacy of aquatic therapy for back pain subjects (McIlveen, et al.).  Furthermore, the patients previous experience with aquatic therapy has proven beneficial. The patient is unable to tolerate land-based therapy. As such, aquatic therapy is a medically appropriate and indicated alternative to land-based therapy. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.