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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for continued physical therapy and occupational therapy services.Treatment options for Parkinsons disease include dopaminergic pharmacotherapy, various exercises, formal rehabilitative interventions, and deep brain stimulation. Researchers hypothesize that exercise may improve gait in Parkinsons disease through multiple mechanisms, but methodological limitations of the existing literature limit the clinical applicability of the findings, and further research is required to evaluate the potential for specific exercise interventions for improving symptoms over time. Researchers state that benefits may be achieved through maintenance programs with high levels of repetitive practice. While formal physical and occupational therapy evaluations and programs may have a role in the management of functional deficits related to Parkinsons disease, the optimal intensities, frequencies and duration parameters for these interventions are unclear. In this case, the patient underwent physical and occupational therapies in the skilled nursing facility and progressed to a contact guard assistance level for her basic mobility, but continued to require assistance for her self-care, particularly for lower body self-care. There were no indications that she had potential to increase her independence in a clinically significant manner. She was transitioned to a long-term care facility setting with plan for maintenance exercises via restorative nursing services, which can meet her basic exercise needs. Therefore, the continued physical therapy and occupational therapy services are not medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Tramadol (Ultram). The enrollee has a history of systemic lupus erythematosus. The enrollee also has osteoarthritis in both hands. A progress note reports the enrollee is taking Tramadol, 50 milligrams daily every 8 hours, but her provider wishes for the enrollee to taper off the medication to 50 milligrams per day, due to its addictive nature.  The progress note reported the enrollee had no major complaints, no major issues, and no symptoms of active lupus. The available documentation indicates that tramadol is being used to treat pain due to osteoarthritis of the hands.  She has not experienced any apparent toxicity. Tramadol is a pain-killer, and treatment of pain is a goal of therapy. A professional society provides Tramadol with a conditional recommendation for therapy. Therefore, it is part of the spectrum of treatment for osteoarthritis of the hands. Tramadol has five morphine milligram equivalents for every 50 milligrams. Therefore, twice daily dosing has 10 morphine milligram equivalents; a very small amount. There is a low risk of addiction. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for a bilateral mastectomy. Findings:  The physician reviewer found that chest surgery in transgender male minors is a common treatment for gender dysphoria. The World Professional Association for Transgender Health (WPATH) states, Chest surgery in female-to-male patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. Olson-Kennedy and colleagues reported that chest surgery in transgender male minors was a safe and effective treatment for gender dysphoria, noting, Chest dysphoria was high among presurgical transmasculine youth, and surgical intervention positively affected both minors and young adults. Given these findings, professional guidelines and clinical practice should consider patients for chest surgery based on individual need rather than chronologic age. In this case, the patient has gender dysphoria and has spent ample time living in the desired gender role and had one year of testosterone treatment. The patients providers report the requested services are medically indicated for the treatment of this patient. Therefore, bilateral mastectomy is medically necessary for the treatment of this patient.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 psychiatry with expertise in transgender health 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 20-year-old female enrollee requested residential treatment center services for treatment of her polysubstance abuse, mood disorder, and anxiety disorder.  Findings:  The physician reviewer found that the records indicate that the patient was not in withdrawal and was showing no signs of post-withdrawal symptoms. She was not medically compromised and her coexisting psychiatric conditions were controlled with medications. According to the American Psychiatric Association (APA) guidelines, the patients course of treatment was not complex and she could have been safely and adequately treated at a less restrictive level of care such as intensive outpatient program (IOP) with community based supportive services including a 12-step program. There was no evidence that the patient represented a risk of harm to herself or others. She was independent in all aspects. She was motivated, cooperative, attended group, and otherwise participated in her treatment plan. Her family was supportive. She expressed commitment and acceptance of her problem with substances. She did not require 24-hour monitoring and did not meet medical necessity criteria for residential substance abuse treatment. For these reasons, residential treatment center services were not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 72-year-old male enrollee has requested Afinitor (everolimus) for treatment of his bladder cancer.  Findings:  Two physician reviewers found that in this patients case, the requested medication is likely to be more efficacious than other treatment options.  Based upon the results of genomic analysis of this patients tumor, there is sufficient support for the requested medication in this clinical setting.  Following a short duration of use of this medication, the records document a favorable response.  This patient has failed treatment with prior chemotherapy regimens.  Therefore, Afinitor is likely to be more effective than other treatment alternatives in this case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested orthopedic inserts for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. Per Medicare guidelines, orthotics may be authorized and/or covered if the orthotics are part of a medically necessary shoe attached to a medically necessary leg brace. After review of the clinical notes submitted for review, the patient does not have a medically necessary shoe attached to a medically necessary leg brace. For this reason, orthopedic inserts are not medically necessary for this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in podiatry 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 immune globulin (IVIG) Gammagard. This patients records document a history of immune mediated necrotizing myopathy resistant to maximum steroid use. The patients provider has recommended treatment with Gammagard IVIG. The provider reports that the patient is at increased risk of aspiration due to her worsened condition and the presence of dysphagia. Treatment with IVIG therapy is indicated for patients with severe life-threatening weakness and those with severe dysphagia at risk for aspiration. In this clinical setting, patients may benefit from the addition of IVIG to initial treatment with glucocorticoids, which is likely to have a more rapid onset of action than glucocorticoids. Treatment with medications such as methotrexate, mycophenolate, and azathioprine are not likely to provide this patient with the positive response as treatment with Gammagard IVIG. For these reasons, the requested IVIG Gammagard 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 internal medicine with subspecialty 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested the Optune electrical stimulation device (Tumor Treatment Fields Therapy) and NovoTAL (Transducer Array Layout) System for treatment of his medical condition.   Findings:  Three physician reviewers found that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Optune TTF, formerly known as NovoTTF, delivers alternating electric fields which are thought to disrupt mitotic activity. The patients wear this device most of the day which delivers electric fields via a portable device through electrodes placed on the patients scalp. NovoTAL allows for better customization of the treatment fields delivered by the Optune device. According to a large multi-institutional prospective randomized controlled trial, the Optune device appeared to be as effective as chemotherapy. Another study included 457 recurrent GBM patients who received TTF therapy. The authors concluded that NovoTTF Therapy offers clinical benefit to patients with recurrent GBM. NovoTTF Therapy has high patient tolerability and favorable safety profile in the real-world, clinical practice setting. In this case, the patient had already received first line salvage systemic therapy with Avastin. TTF therapy was indicated as an effective treatment for this patients disease.   Final Result: Three reviewers determined that the services at issue were 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:  One reviewer is board certified in radiation oncology and is actively practicing.  One reviewer is board certified in neurological surgery and is actively practicing.  One reviewer is board certified in internal medicine with sub-specialty certification in oncology and is actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for escalation frequency of Stelara 90 mg/mL x 1 injection every 28 days. The current peer-reviewed medical literature supports the requested dose escalation of Stelara from 90 mg/mL every eight weeks to every four weeks. One study found that Stelara dosing at 90 mg every four weeks can address inadequate disease control with a large proportion of patients able to maintain response with dose escalation to 90 mg every four weeks (Kopylov, et al.). Multiple studies have shown that a majority of patients in whom Stelara dosing every eight weeks failed to control symptoms responded to dosing every four weeks (Battat, et al.; Khorrami, et al.). The records provided for review document that this patient has failed conventional therapy including mesalamine, Remicade with azathioprine, and Xeljanz, which are recommended for the treatment of ulcerative colitis. The patient then experienced improvement with Stelara. The patient had a low Stelara level when dosed every eight weeks and reported urgency even on the higher dose of 90 mg every four weeks. As the patient demonstrated initial improvement on Stelara with but a low Stelara level, and then improvement but ongoing urgency on dosing every four weeks, continuation of Stelara 90 mg every four weeks is supported. Discontinuation of the current dose of  90 mg every four weeks or a change to another medication may be ineffective and may result in complications. For these reasons, the requested escalation frequency of Stelara 90 mg/mL x 1 injection every 28 days is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication dosage is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee has requested for a home cervical traction unit (Saunders Home Tract) for treatment of her cervicalgia. Findings:  The physician reviewer found that the over-the-door unit produces pressure on the temporomandibular joint (TMJ) and her providers clearly indicated the patient cannot tolerate this type of pressure. The Saunders cervical traction unit is a medically reasonable alternative due to the patients TMJ.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old male has requested intravenous IVIG for treatment of his chronic inflammatory demyelinating polyneuropathy.  Findings:  The physician reviewer found that this patient has had progressive upper limb weakness, with examination and test results showing lower motor neuron abnormalities.  The current medical literature indicates that the diagnosis of chronic inflammatory demyelinating polyneuropathy is made based on history, examination, electrodiagnostic study, and may be supplemented by cerebrospinal fluid examination and relevant biopsies.  The current medical evidence supports intravenous IVIG treatment for the treatment of chronic inflammatory demyelinating polyneuropathy.  As IVIG is shown to be appropriate for chronic inflammatory demyelinating polyneuropathy, and this patient has had findings which are consistent with this diagnosis, IVIG treatment is medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 61-year-old female with chronic hepatitis C active viral replication, genotype 1. She did not respond to treatment with interferon and ribavirin. The patient was then started on Pegasys and Copegus; however, due to side effects she was switched to PEG Intron, which she also was unable to tolerate. She was ultimately started on Infergen and Actimmune. The patient is also receiving treatment with Procrit. The Health Plan has denied coverage for Actimmune and Procrit on the basis these medications are not medically necessary.Infergen (interferon alfacon-1) is FDA approved for patients with hepatitis C who are non-responders. Actimmune (interferon gamma-1b) does not have FDA indication for hepatitis C therapy. There is insufficient evidence Actimmune is beneficial for treatment of the patients condition. As such, the use of Actimmune in this clinical setting is not medically necessary. Regarding the patients request for Procrit, sustained viral response is key in this patient. The drop in hemoglobin is of concern, as any level at or below 10 should be taken seriously. Addition of Procrit to her regimen is medically reasonable and appropriate. Many studies have looked at the benefits of the addition of growth factors such as Procrit and Neupogen in HCV-infected patients. Use of Procrit is medically reasonable and appropriate and is a needed therapeutic approach in this patient who, though responsive to medicinal therapy, has had problems with side effects. Procrit should be authorized to enable the patient to finish her course of therapy.Based upon the information set forth above, I have determined that although Actimmune is not medically necessary for treatment of the patients medical condition, Procrit is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee has requested reimbursement and prospective authorization and coverage for speech therapy twice per week for treatment of the enrollees dysfluency/stuttering.  Findings:  The physician reviewer found that stuttering affects the fluency of speech. It begins during childhood and, in some cases, lasts throughout life. Although most young children recover from stuttering, if the child is already older than 6 years of age, the spontaneous recovery will be less likely. In his preliminary study of case histories, Millards hypothesis was that early intervention with young dysfluent children is more successful over a shorter period of time than if speech and language therapy is delayed. The amount and duration of speech and language therapy along with the outcome was measured. The author concluded that preliminary findings indicate that early intervention is effective. Millard also looked into intensive therapy but looked at it in terms of group therapy. She looked at the effectiveness of a 2 week program and concluded that the results she obtained provided evidence supporting the effectiveness of intensive group therapy. Therefore, the requested speech therapy is medically necessary twice per week for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old male enrollee has requested a DOPA positron emission tomography (PET) scan for the evaluation of his possible seizure activity. Findings:  The physician reviewer found that the National Comprehensive Cancer Network (NCCN) advocates for brain MRIs as the gold standard of brain tumor imaging. PET scans are also mentioned in the NCCN guidelines as a means to differentiate radiation necrosis from recurrent tumor. PET scans can also be used to locate a site for optimal biopsy. According to Wong and colleagues, FDG-PET is less sensitive than contrast enhanced MRI for detecting intracranial metastasis. Review of the peer-reviewed literature showed anecdotal use of DOPA PET scan in the evaluation of tumors of neuroendocrine origin. However, there is very little literature support for DOPA PET scan in the evaluation of patients with anaplastic astrocytoma who are experiencing seizure activity.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee requested authorization and coverage of an open MRI of the spine for the treatment of back pain.  One Physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the plan's denial on the basis that the requested prescription is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The records document that this patient has been diagnosed with relapsing remitting multiple sclerosis (RRMS). Currently there are several treatment options available for the treatment of this progressively neurodegenerative disease process. The available medications include therapies that are injections, oral therapies, as well as infusion therapies. Oral therapies are often better tolerated in patients due to reduced side effects and the ability to avoid daily injections. Interferon therapies such as Avonex and Betaseron are known to cause a flu-like reaction. Other injectable therapies such as Copaxone are known to cause lipoatrophy and can lead to disfiguring dimple like changes at the site of the injections. Oral medications are often better tolerated and do not cause these types of side effects thereby increasing compliance. Dimethyl fumarate (Tecfidera) is a U.S. Food and Drug Administration (FDA) approved oral therapy for the treatment of RRMS. Tecfidera has demonstrated better relapse reduction rate than traditional interferons and Copaxone. In this particular case, the patient is likely to benefit from taking this therapy. Thus, the requested Tecfidera is supported as medically necessary for treatment of this patients RRMS. 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.