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

The parent of a two-year-old female enrollee has requested  for speech therapy and physical therapy for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that the use of speech therapy significantly helps these patients communicate and learn to function since they have delays in their developmental attainment of milestones. As a result of the hypotonia, patients may suffer from apraxia of speech as well. Therapy is tailored to the individual patient and is designed to treat other speech or language problems that may occur together with apraxia. Each patient responds differently to therapy, and some make more progress than others. Patients with apraxia of speech usually need frequent and intensive one-on-one therapy. Support and encouragement from family members and friends are also important. Uyanik and colleagues evaluated 45 children with Down syndrome and divided them into 3 groups consisting of sensory integrative therapy, vestibular stimulation in addition sensory integrative therapy and neurodevelopmental therapy. The authors concluded that sensory integration, vestibular stimulation and neurodevelopmental therapy were effective treatment for children with Down syndrome. Overall, they found that when designing rehabilitation programs for children with Down syndrome, all treatment methods should be applied in combination, and should support each other according to the individual needs of the child.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old male enrollee has requested for sub-acute inpatient detox services for treatment of his substance abuse. Findings:  The physician reviewer found that the patient had no clinical or behavioral condition that required 24-hour care. Furthermore, there is no documented failure of care at a lower level of professional intervention, such as partial hospitalization or intensive outpatient care, or that there was a contraindication to such care.  There is also no evidence that the patient lacked an appropriate supportive network.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Praluent 75 mg/mL pen injector. Findings:  The physician reviewer found that Praluent is a PCSK9 inhibitor approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL-cholesterol. The documentation does not support that the patient has either condition. Specifically the Dutch lipid criteria for heterozygous familial hyperlipidemia is not met. Familial hypercholesterolemia usually manifests by a combination of physical exam findings which are not present in this patient, LDL-cholesterol levels that are usually significantly higher than this patients level of 188 mg/dl, genetic confirmation that is not documented, and a personal history of premature vascular disease, which also is not documented. In addition, PCSK9 inhibitors have not been studied in other patient populations such as this case. Also current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting.  Finally, there are other statin medications such as pitavastatin and fluvastatin that have lower side effect profiles and have not been documented to be tried or not tolerated in this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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: Overturned

The representatives of a 38-year-old male enrollee requested authorization and coverage of continued skilled nursing facility care. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested services are medically necessary.
Appeal type: Urgent Care
Decision: Overturned

A 50-year-old male enrollee has requested an emergency room visit for the treatment of his coughing and abdominal pain. Findings:  The physician reviewer found that the symptoms of difficulty breathing, excessive coughing, abdominal/chest pain are consistent with a variety of potentially life-threatening emergent medical conditions including exacerbation of asthma, pneumothorax, pneumonia, and other respiratory disorders. It is reasonable for a prudent layperson to access emergency medical care for such symptoms. Although he had seen his physician on the previous day, his condition worsened despite being prescribed additional medications to treat his respiratory distress.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old female has requested speech therapy and physical therapy for treatment of her pervasive developmental disorder, not otherwise specified. Findings:  The physician reviewer found that according to guidelines for the treatment of autism set forth by the American Academy of Neurology and Child Neurology Society in 2000, the immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach, and can include one or more of the following professionals: psychologists, neurologists, speechlanguage pathologists and audiologists, pediatricians, child psychiatrists, occupational therapists, and physical therapists, as well as educators and special educators. The guidelines support evaluation and treatment of sensorimotor skills including assessment of gross and fine motor skills, praxis, sensory processing abilities, and unusual or stereotyped mannerisms, and the impact of these components on the autistic persons life. Additionally, early identification of speech and language problems is recommended in order to initiate early intervention, which has been shown to improve outcomes for children who have ASD. In this patients case, her motor skills have been noted to be moderately low and she has documented receptive and expressive language delays. Therefore, she is likely to benefit from speech therapy and physical therapy, which are standard modalities for patients with ASD.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case SummaryThe patient has requested authorization and coverage for a Cologuard cancer screening test. Findings:  The physician reviewer found that evidence on healthcare outcomes of Cologuard versus standard medical care is lacking at this time. Cologuard is U.S. Food and Drug Administration (FDA) approved to test for colon cancer, proved 92% sensitive for detection of colon cancer, and can detect some adenomas if they have high-grade dysplasia . However, the limited evidence for Cologuard suggests that 154 patients would have to be screened to find one cancer using colonoscopy, versus 166 patients using Cologuard . In addition, there is a lack of consensus in clinical guidelines form the United States Preventive Services Task Force and the American Cancer Society to support that Cologuard has a positive impact on health outcomes as guidelines. Moreover, although Cologuard may be able to determine that cancer has already developed, it cannot detect and remove polyps or precancerous lesions so that cancer does not develop. Furthermore, Cologuard may be indicated for patients with average risk for colon cancer, but not elevated risk as in this case with a positive fecal immunochemical test (FIT) test. For these reasons, Cologuard is not supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure 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 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 parent of a 14-year-old male enrollee has requested the growth hormone (GH) therapy with Nutropin for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that although the patients height is two standard deviations below normal for age and gender, his growth factors are normal, there is no documentation of an abnormal growth velocity as measured over a one year period, and there is no known morphologic abnormality of his pituitary gland. Results of laboratory tests demonstrating that all other causes of short stature have been ruled out, including occult systemic disease and celiac sprue, have not been provided. Further, a longitudinal growth chart documenting that the patients rate of weight gain has been adequate to support growth is not included for review. All told, the patient does not meet criteria for classic GH deficiency. Based on the bone age, the patients estimated final adult height is 64-65 inches, using the Bayley-Pinneau method. This height prediction is not short enough to warrant GH therapy based on the U.S. Food and Drug Administration (FDA) criteria for treatment of idiopathic short stature. Therefore, the requested GH therapy with Nutropin is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 69-year-old male enrollee has requested C-Brace Orthotronic Mobility System for treatment of his right knee pain secondary to polio and osteoarthrosis of lower leg.  Findings:  Three physician reviewers found that the C-Brace Orthotronic Mobility System is not supported in the peer-reviewed medical literature as superior to standard KAFO devices. There is a lack of published information on its utility, the ideal patient population for its use, or the clinical outcomes of patients who using this device. This patient has utilized a KAFO for an unspecified time period. It is unlikely that a C-Brace would be able to provide similar support or prevent genu recurvatum, which is a condition that afflicts many post-polio patients. Further, the patients physical examination notes do not include sufficient detail demonstrating the patients ability to navigate a C-Brace orthosis. As there is insufficient clinical evidence supporting the use of a C-Brace Orthotronic Mobility System for the use in post-polio patients, the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

This patient is a 10-year-old male with short stature. The patients physician began treatment growth hormone therapy and the patient has responded well. The patients parents are requesting continued treatment with growth hormone therapy. In my review of the records I have found the patient to have idiopathic short stature, which was not attributed to growth hormone deficiency or other definable syndrome. He was given growth hormone therapy at 7.5 years at a time when his height was well below the first percentile and he has shown a gratifying and protracted growth response to lie between 10th and 25th percentiles by 10.5 years. On medical grounds, growth hormone therapy should be continued as long as the patient continues to respond or until growth has ceased. In addition, growth hormone therapy for patients such as this patient is supported by the Food and Drug Administration and the American Association of Clinical Endocrinologists (see citation above). Continued growth hormone therapy is medically reasonable and appropriate for this patient. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old female enrollee has requested a power operated wheelchair for her impaired mobility secondary to rheumatoid arthritis. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity for a power wheelchair in this case. Specifically, this patient is unable to ambulate despite use of an assistive device and she is also unable to self-propel a manual wheelchair. She requires a power wheelchair to perform in home mobility-related activities of daily living. It has been documented that she is able to operate a power wheelchair. Further, her home environment can accommodate a power wheelchair.
Appeal type: Medical Necessity
Decision: Upheld

A 28-year-old female enrollee has requested mental health outpatient therapy for treatment of her behavioral health issues. Findings:  The physician reviewer found that the outpatient psychotherapy services provided during the time period at issue are not supported as leading to demonstrable improvement in the patients functioning, despite significant frequency over a long period of time. Consistent with the Health Plans recommendation, the patient required a more intensive treatment program and therefore intensive outpatient program (IOP) or partial hospitalization program (PHP) services would have been considered medically necessary modalities for this patient. Given the lack of potential for benefit, the outpatient psychotherapy provided during the time period at issue was not medically necessary.  With regard to continuation of outpatient psychotherapy at this time, there is little evidence demonstrating that the requested twice weekly therapy without medication management will afford any better or even equal outcomes compared to the patients past regimen. The standard of care in this setting includes consideration of IOP treatment or dialectical behavioral therapy available in forums such as the PHP setting. Such programs offer medication management and monitoring to attenuate the patients symptoms of depression and anxiety. There is no peer reviewed data demonstrating that ongoing outpatient psychotherapy without concomitant medication management is likely to result in clinically significant improvement in daily function in this setting. As such, the requested twice weekly outpatient psychotherapy sessions are not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old male enrollee has requested Lyrica for treatment of his pain.  Findings:  The physician reviewer found that the treatment of neuropathic pain of any etiology can be managed with membrane stabilizing agents such as Lyrica and Neurontin. These medications are generally part of first-line therapy and are an integral part of a comprehensive management strategy for difficult to control neuralgia that can come from multiple underlying causes.  In many cases, Lyrica is used off-label if the patient fails to obtain relief from Neurontin.  The indications for Lyrica include neuropathy from post shingles pain, diabetes, pain from fibromyalgia, and seizure control for complex partial seizures.  However, it is common to see off-label uses for other chronic pain syndromes, especially neuropathic pain syndromes.  In this case, the patient has already failed Neurontin due to side effects.  Lyrica is very similar in mechanism of action, but is generally better tolerated.  In this patients case, due to the chronic refractory nature of the pain and good response to the medication at issue, Lyrica was and is medically indicated from the date in question forward.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee requested authorization and coverage of the medication sodium phenylbutyrate for the treatment of breast cancer.  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 the medication sodium phenylbutyrate is not likely to be more beneficial for treatment of the enrollees breast cancer 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested lumbar spinal fusion for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient presents with persistent and worsening low back pain radiating into the left lower extremity. The patient reports functional difficulty in work and daily activities. Clinical examination findings are consistent with imaging evidence of disc pathology. There is imaging evidence retrolisthesis reported by the radiologist and the treating physician. Detailed evidence of at least six months of reasonable and/or comprehensive nonoperative treatment protocol trial and failure has been submitted. However, there is no radiographic evidence of spinal segmental instability on flexion and extension x-rays meeting instability criteria of 4.5 mm of translational movement. There is no discussion or imaging evidence supporting the need for wide decompression that would result in temporary intraoperative instability and necessitate fusion. Therefore, the requested lumbar spinal fusion is not medically indicated for the treatment of 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 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: Upheld

The patient is a 49-year-old male with stage T1c Gleason grade 3+3 (total 6) adenocarcinoma of the prostate noted in 1 mm of 8 biopsy cores with pre-biopsy PSA of 3.3. The patient has requested treatment with a robotic-assisted laparoscopic radical prostatectomy. The Health Plan has authorized a radical retropubic prostatectomy, with bilateral pelvic lymphadenectomy. The Health Plans denial should be upheld. The robotic-assisted laparoscopic procedure is relatively new, and while short-term results are comparable, long-term data especially with regard to survival is not yet available. While there is no medical objection to the robotic-assisted laparoscopic approach, to date there is insufficient data to demonstrate its superiority to other procedures. The open surgical approach is a well-established treatment with good long-term results regarding survival and complications and is considered standard of care for treatment of the patients prostate adenocarcinoma. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (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 1a patients should be treated with regimens including Zepatier (with ribavirin when NS5A resistance is found) and Epclusa. However, although the U.S. Food and Drug Administration approved prescribing information for Zepatier reports that liver enzymes may rise with Zepatier, this is typically asymptomatic and resolves with ongoing or completion of therapy, and discontinuation could be considered if ALT levels remain persistently greater than 10 times the upper limit of normal or there are concurrent signs or symptoms of liver inflammation or increasing conjugated bilirubin, alkaline phosphatase, or international normalized ratio. This patient has an elevation in ALT, but these criteria are not met.  Therefore, there is no medical contraindication to Zepatier in this case. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, although treatment of hepatitis C is medically necessary in this case, Epclusa is not medically necessary for the treatment of this patient. 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 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

A 53-year-old male enrollee has requested an increase in Humira for the treatment of his rheumatoid arthritis. Findings:  The physician reviewer found that this patient continues to have active and inadequately controlled rheumatoid arthritis as described by his rheumatologist, and he has already failed Enbrel in standard as well as increased dosage. He had an initially good response to biweekly Humira, but then lost benefit. This is a fairly common circumstance in rheumatologic practice, for although the original trials and approval for the use of Humira in rheumatoid arthritis involved biweekly dosing, it is clear that a substantial number of patients require 40mg weekly dosing for adequate benefit. A number of studies have shown that the concomitant use of methotrexate with Humira or other TNF inhibitors leads to better responses than does the use of either agent alone.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old male enrollee has requested wireless capsule endoscopy for an evaluation of his abdominal pain. Findings:  The physician reviewer found that this patient suffers from vague abdominal pain with a rather unremarkable EGD and Colonoscopy. Based on information provided, the diagnosis of possible Crohns disease in this patient is not supportable. Thus, the need for a wireless capsule endoscopy is not supported by the record at this time.