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

A 64-year-old male enrollee has requested an Omnipod insulin pump for the treatment of his diabetes. Findings:  The physician reviewer found that the submitted records do not substantiate the medical necessity of an insulin pump or the Omnipod pump in particular. An insulin pump may be indicated if there is documented evidence that the patient is unable to maintain control despite frequent checks of his blood sugar (at least 4 times daily). While the records suggest that the patient is monitoring, a monitoring log documenting the frequency of the testing has not been provided. Thus, given the absence of data to support a specific need for an insulin pump, the medical necessity of an insulin pump has not been established. Furthermore, other than the fact that the Omnipod pump does not require a catheter which can be pulled or caught, no evidence has been provided that the Omnipod is superior to a standard insulin pump. As such, the Ominipod pump would not be necessary for this patient from a medical standpoint.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested acupuncture services for treatment of her medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The current medical evidence does not support acupuncture services in this clinical setting.  The patient underwent prior acupuncture she reported that acupuncture partially relieved pain.  However, the records do not document examination findings, such as significant reduction of range of motion, positive orthopedic findings or functional-motor-sensory deficits, which would support the necessity of acupuncture services.  All told, acupuncture services are not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were not and 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 oriental medicine with sub-specialty certification in acupuncture and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Pradaxa. The American College of Chest Physicians (ACCP) 2016 guideline recommends long-term (first 3 months) anticoagulant therapy for patients with DVT of the leg or PE and no cancer. The ACCP suggests Pradaxa (dabigatran), and other medications over vitamin K antagonist (VKA) therapy (all Grade 2B). The ACCP states that several of the direct oral anticoagulants (DOAC) are equally effective. At this time, there are reversal agents available: Praxbind for Pradaxa. These reversal agents are noted to be effective in rapidly reversing the anticoagulant effect of DOACs.In this case, the patient meets the 2016 ACCP criteria for extended anticoagulation based upon recurrent VTE of legs and pulmonary embolism. The patient has been stable on Eliquis for over 12 months without complication or recurrence of VTE. The ACCP clearly states that there is no significant difference in effectiveness for any of the four available DOACs. The potential need for a reversal agent does not warrant changing from one DOAC to another. Patients can moderate their activities and lifestyle to minimize the risk of bleeds. Both Pradaxa and another drug carry a low bleed risk. Under these circumstances, the medication Pradaxa is not medically necessary for treatment of the patients medical condition.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 subspecialty certifications in hematology and medical oncology, 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 guidelines issued, 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. These guideline recommendations are based on multiple randomized clinical trials. For these reasons, the requested treatment with 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for language therapy services five times per week using the PROMPT method. Findings:  The physician reviewer found that records provided for review document that this patient has a history of chromosome 5 deletion with submucosal cleft palate, bifid uvula, abnormal oral frenulum, and corpus callosum abnormalities. The patient has received speech therapy using the PROMPT method five times per week for the past 12 years for the treatment of apraxia of speech. The American Speech-Language-Hearing Association (ASLHA) reported that in the treatment of childhood apraxia of speech, The core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody. The PROMPT method involves a tactile approach where the provider helps guide a patients jaw, lips, and tongue to move correctly to form speech. This patients documentation does not include standardized evaluations of the patients speech and language function. The providers notes indicate that the patients progress has been inconsistent and minimal, which suggest that the patient has likely plateaued. The provider charted that the patient demonstrates significant fluctuation in her performance from day to day, typically imitating two-word phrases with 65-90% accuracy. The patient has intellectual disability and does not do well with unfamiliar people and settings. The medical literature supports maintenance speech therapy services using the PROMPT method at a frequency of twice per week, which is in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Therefore, the requested language therapy services two times per week using the PROMPT method are medically necessary for this patient. 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 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 17-year-old male enrollee has requested for residential treatment for treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found that this patient had experienced worsening substance use and symptoms of mental illness prior to his admission. He had a history of two hospitalizations after suicide attempts. Based on the American Academy of Child and Adolescent Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS), the patient met criteria for residential treatment.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency services. The Health Plan has denied this request indicating the services at issue were not necessary for treatment of an emergency medical condition. According to the documentation submitted for review, the patient was found by paramedics in anaphylactic shock, likely due to ingestion of shellfish. Documents provided note the enrollee improved with intramuscular epinephrine as well as intravenous fluids and diphenhydramine. The enrollee was subsequently administered intravenous steroids as well. The half-life of intramuscular epinephrine is brief. The medical literature notes the existence of a biphasic reaction to food induced anaphylaxis (FIA) wherein recurrent symptoms occur following the resolution of the initial reaction. These reactions occur in 5% to 25% of patients with anaphylactic reactions, with the highest incidence involving FIA.  It is unclear whether the administration of epinephrine or steroids can prevent such reactions. Therefore, an observation period of four hours from the time of symptom resolution is recommended prior to discharging such patients.  Moreover, documented in the history and physical, completed three hours after the patients arrival in the emergency department, the patient still had periorbital swelling. Therefore, observation was required until the patients facial swelling had resolved, and for four hours following resolution of the symptoms. Due to persistent facial swelling, this patient was not stable for discharge from the emergency department. The risk of a biphasic response to FIA requires a four-hour period of observation following symptom resolution. As such, the hospital admission provided was emergency medical services as defined by California law.Final Result: The reviewer determined that the patient received emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with bilateral knee osteoarthritis. The patient reported right knee pain, swelling, and functional limitations. The physical examination revealed right knee patellofemoral tenderness. The patient had been treated with viscosupplementation injections in the past. Prior right knee viscosupplementation injections were noted to provide 90% pain relief for five months. The patient has requested authorization and coverage for Orthovisc injections in the right knee only. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Orthovisc injections in the right knee only are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, there is a history of lasting benefit from prior viscosupplementation injections. Additionally, the options are limited, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Orthovisc injections in the right knee only are 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 orthopedic 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 authorization and coverage for Praluent for treatment of the enrollees dyslipidemiaFindings:  The physician reviewer found that this patient has marked elevation of cholesterol and LDL, which is consistent with heterozygous familial hypercholesterolemia. Treatment with statins has not been tolerated and has not been effective in lowering the patients cholesterol to a goal level. The U.S. Food and Drug Administration (FDA) approval recommends Praluent as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia or clinical atherosclerotic cardiovascular disease, who require additional lowering of LDL cholesterol. Due to the high baseline of this patients LDL, the patient has a genetic disorder and would likely benefit from use of Praluent. 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 cardiovascular disease 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: The patient has requested authorization and coverage for palliative care. In this case, the patient has a past medical history significant for chronic lumbar radiculopathy, left rib pain, PTSD, depression and multiple concussions with loss of consciousness. However, the medical literature does not support the use of palliative care for any of this patients medical conditions. In addition, the documentation does not indicate that the patient has a terminal condition which would benefit from palliative care. Moreover, the records do not provide a specific rationale to support the request for palliative care. All told, the requested palliative care is not medically necessary for 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 anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ultralight aluminum frame wheelchair with smart drive power assist. The submitted documentation fails to demonstrate the medical necessity of the requested equipment. Pushrim-activated power-assisted wheels reduce the forces required to propel manual wheelchairs, particularly on inclines and over high friction surfaces.  Primarily, the benefits are the reduction of load on the arms and decrease on cardiopulmonary demand.  It is not proven that there are reduced forces or moments exerted at the rim, or that there are benefits with respect to repetitive use injuries at any point in the kinetic chain. In the present case, the patient is reported to have instability at the wrists and carpal tunnel syndrome.  Gripping and grasping are reported to be challenging.  Ongoing use of a manual wheelchair in this clinical setting, with or without power assist wheels, would not be expected to be tolerated. Therefore, the requested ultralight aluminum frame wheelchair with smart drive power assist is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 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

The patient is a 17-year-old male with a complicated medical history of intractable epilepsy and intractable myasthenia gravis, which has been moderately responsive to frequent plasma exchange. He has bulbar weakness and chronic secretion problems. A request has been made for coverage for the Vest System, an oscillatory device to treat the patients ongoing breathing problem. The Vest System is medically indicated given the patients prior response to therapy and the high-risk of life threatening aspiration. Standard treatment modalities are not available to this patient in light of his myasthenia gravis and previous sternotomy. As such, use of the Vest System is medically reasonable and appropriate and should be continued. Therefore, I have determined the requested equipment is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested Botox injections for medical treatment of her migraine headaches.  Findings:  The physician reviewer found that the medical records submitted for review do not adequately document a history of chronic migraine or a history of adequate trials of three classes of anti-migraine medications. In addition, there is no mention of headache diaries, or documentation of previous use of other medications. Based on the clinical records submitted, there is a lack of documentation to establish the medical necessity for the requested Botox injections.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old female enrollee has requested Byetta for treatment of her type 2 diabetes mellitus. Findings:  The physician reviewer found that it is a well-accepted fact within the medical community that a diabetic with a lower hemoglobin A1c has a correspondingly lower risk of further deterioration of all at-risk bodily systems including the eyes, the nerves and the kidneys. Byetta is specifically approved for use in combination with metformin. In the case of a type 2 diabetic, it is not an insulin substitute as it would be for a type 1 diabetic, it is simply a better method of managing blood glucose. Previous use of insulin is not a contraindication for treatment with Byetta, particularly in light of the benefit the patient has derived from this medication.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested a transfer to an acute rehabilitation unit for treatment of her metastatic breast cancer to the brain. Findings:  The physician reviewer found that from a review of the available records, it appears that the patient is now ready for treatment at a lower level of care and requires the services available at a skilled nursing facility. She is currently an inpatient, but in order to transfer to an acute rehabilitation unit, a patient needs to have good rehabilitation potential and must be able to tolerate intensive rehabilitation on a daily basis. This patients records show that as an inpatient she had occupational and physical therapy evaluations that demonstrated the inability to ambulate, extreme weakness and multiple other deficits. At this time, the patient has very low potential for rehabilitation and could not tolerate the amount of therapy expected at an acute rehabilitation facility. In addition, there is no indication in the records that a physician or other provider has recommended or ordered the requested transfer to an acute rehabilitation unit. For these reasons, a skilled nursing facility is the most appropriate level of care for this patient at this time considering her current medical status and lack of potential.