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

A 57-year-old female enrollee has requested therapy at a frequency of one or two times per week for treatment of her major depressive disorder. Findings:  The physician reviewer found that the medical necessity for therapy at a frequency of one to two times per week has not been established. This patient has participated in therapy for many years.  However, her GAF score has remained consistent. She has never been hospitalized, and there is no history to indicate that she has ever presented a serious risk to self or others. There is no indication of progress towards a defined set of treatment goals. There is no indication that the therapist has made or is making attempts to decrease the frequency of visits or foster involvement in community resources. The data reviewed do not indicate that a decrease in frequency will likely be detrimental to the patient or result in her requiring a higher level of care. American Psychiatric Association practice guidelines indicate that patients should be treated in the least restrictive setting which is likely to be safe and effective.  There is no evidence that the patients safety would be compromised by decreasing the frequency of visits to once every two weeks. In this patients case, outpatient treatment at a frequency of once every other week was and is medically appropriate.  All told, therapy at a frequency of one or two times per week was not and is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of his treatment experienced chronic hepatitis C virus genotype 1a.  Findings:  Two physician reviewers 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 virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. These 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. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. For these reasons, the requested treatment with Harvoni for 12 weeks is medically necessary for treatment of this patients hepatitis C virus infection. Final Result: Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Otezla 30 mg for treatment of the enrollees psoriasis. Findings: The physician reviewer found that Psoriasis is a chronic inflammatory skin disease that typically presents with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation and parakeratosis secondary to the inflammation. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. About 20% of patients have severe psoriasis, necessitating systemic drugs such as acitretin, methotrexate, cyclosporin A or the newer biologic agents. The long-term use of traditional systemic therapies is frequently unacceptable because of renal, hepatic, pulmonary toxicity and limited efficacy. Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of anti-tumor necrosis factor (TNF) biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus. It has been well-documented that therapies of psoriasis with injectable biologics increase the risk for malignancy and infection, mandating prior testing for tuberculosis. Apremilast (Otezla) an oral PDE4 inhibitor, provides a novel therapeutic option for the treatment of patients with moderate to severe plaque psoriasis. Its effects on cyclic adenosine monophosphate-regulated intracellular signaling, gene expression, and subsequent protein levels allow apremilast to modulate the immune responses that cause the inflammation associated with psoriasis. Otezla has been shown to result in significant improvement in well selected patients. Otezla has been studied in more than 4,000 patients, and the safety profile is consistent across indications. This patient has chronic plaque psoriasis that requires systemic treatment. Immunosuppressive and anti-TNF drugs can increase the risk for infection and malignancy. Otezla is approved by the U.S. Food and Drug Administration (FDA) for treatment of such patients. For these reasons, the requested Otezla 30 mg is supported as medically necessary for treatment of this patients plaque psoriasis.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 dermatology 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 Supartz injection series in left knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, there is a history of prior viscosupplementation of the left knee with excellent results. Furthermore, the patients current treatment options are limited. The alternative is a total knee arthroplasty, which the patient would like to avoid due to her experience with the right knee replacement and revision. As such, the requested Supartz injection series in the left knee is medically necessary for 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 Sovaldi and for treatment of her 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 and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, genotype 2 patients should be treated with daily Sovaldi and weight-based ribavirin 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 2 regardless of fibrosis stage.  All told, Sovaldi and ribavirin are medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medications 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 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 49-year-old female enrollee has requested Gralise ER 600mg for treatment of her chronic low back pain and fibromyalgia.  Findings:  The physician reviewer found that based on review of the available records, gabapentin (Gralise) is medically necessary for treatment of this patients medical condition. The records provided for review document the patient has tried and failed to benefit from standard therapies including medications and physical therapy for neuropathic and generalized body pain due to post-laminectomy syndrome and fibromyalgia. The patient has tried generic gabapentin, and although it was effective, it caused extreme sedation. However, the patient reportedly had a good response with Gralise. Additionally, Gralise is supported in the peer-reviewed medical literature as a safe and effective treatment for several neuropathic conditions. Gilron reviewed the evidence-based literature supporting the use of Gralise use for chronic neuropathic and early post-surgical pain. The author reported that multiple, large, high quality trials have demonstrated the safety and efficacy of Gralise in neuropathic pain. Further, Serpell and colleagues performed a double-blind, randomized, placebo-controlled study to evaluate the efficacy and safety of gabapentin in the treatment of neuropathic pain, using doses up to 2400 mg per day. Patients had a wide range of neuropathic pain syndromes. At the end of the study the authors concluded that, gabapentin was shown to reduce pain and improve some quality of life measures in patients with a wide range of neuropathic pain syndromes. Thus, the requested Gralise ER 600mg is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old male has requested occupational therapy for one hour per week for treatment of his autistic disorder.  Findings:  The physician reviewer found that in reviewing the available peer reviewed medical literature and the records provided, it is well established in the neurological community that despite underlying neurologic disease, there remains plasticity in the developing brain which can be utilized to improve overall neurologic health. Thus, specific treatment, including occupational therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to autistic spectrum disorders and their co-morbidities including, but not limited to repetitive or stereotypic behaviors as well as deficits in communication, play skills, and self-help skills. Occupational skills relevant to age-appropriate activities of daily living and to a lesser degree, non-verbal skills improve with long-term application of occupational therapy during critical developmental periods in childhood. This conclusion continues to be supported by relevant studies, most recently the one by Papavasiliou et al. (2011), which documented a clear improvement in Childhood Autism Rating Scales (CARS) with occupational therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 79-year-old male enrollee has requested emergency transport for treatment of his medical condition.  Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would have believed that emergency transport to the hospital was medically necessary. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.The submitted documentation states that the patient was worried about pain in his chest. However, the paramedic notes specifically state that the patient denied any chest pain or shortness of breath. The patient complained only of nausea that commenced after eating breakfast. Upon arrival in the Emergency Department, the patient reported abdominal cramping. He then left the facility prior to evaluation by a physician. It is unlikely that a prudent layperson experiencing nausea after breakfast would reasonably believe his condition requires the emergency services that only an emergency ambulance transport can provide. This is supported by the fact that the patient then decided to leave the hospital prior to an examination or complete evaluation. While the patient is of advanced age, the submitted documentation does not establish that the patient was experiencing symptoms of such severity that they would cause a prudent layperson in his situation to believe emergency transportation was required to prevent serious injury.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee requested authorization and coverage of the medication Lotronex. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees irritable bowel syndrome.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a two-year-old male has requested coverage for occupational therapy at a frequency of two sessions per week for 60 minutes per session for treatment of his sensory processing disorder.  Findings:  The physician reviewer found that although anecdotal support exists regarding treatment of sensory processing deficits with occupational therapy, there is a paucity of sound evidence regarding its effectiveness as there are few well-controlled studies that exist which examine the effectiveness of frequently used pediatric occupational therapy with well-defined, homogenous populations on outcomes that target participation in everyday life (Polatajko and Cantin). A systemic review by Polatajko and Cantin found that children with difficulty processing and integrating sensory information and difficulties with the performance of daily occupations can benefit from intervention, however, no firm conclusions can be made regarding specific approaches due to poor study quality and great variability in interventions and patient populations. The occupational therapy sessions the patient has received in the past have concentrated on sensory processing issues and decreased oral and fine motor coordination. The initial occupational evaluation did not quantify the functional limitations in daily living skills and fine motor skills. All told, there is a lack of documentation of standardized testing of fine motor and daily living skills (i.e., Vineland II or other appropriate fine motor testing) that describes the extent of the patients delays and demonstrates that occupational therapy has been beneficial. Given the lack of peer reviewed data supporting the requested modality as well as the limited documentation of the patients current deficits and/or progress, the requested occupational therapy is not medically necessary in this case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a myoelectric prosthesis socket that is used for activities of daily living, such as getting dressed, used in classes at school, making food, two-hand holding of objects, and a body-powered prosthesis socket that has different terminal devices to aid the activities of daily living, such as the enrollees physical education class for treatment of the enrollee, who has been diagnosed with left wrist congenital transverse deficiency with radial head dislocation. Findings:  The physician reviewer found that the medical literature indicates that the prosthesis is a fabricated substitute for missing limbs. Myoelectric prostheses are recommended for patients who have sufficient neurological, myocutaneous and cognitive function to operate the prosthesis effectively.  There should be evidence that standard body-powered prosthetic devices cannot be used or that they are insufficient to meet the functional needs of the patient to perform activities of daily living. Body-powered prostheses have been shown to have the advantage of durability, frequency of adjustment, and maintenance. However, they could still benefit from improvement in control. Myoelectric prostheses have been shown to improve cosmesis and phantom-limb pain and are more accepted for light intensity work.  Prosthetic selection should be based on the patients individual needs and include personal preference, prosthetic experience and functional needs. The documentation provided for review indicates that the patient has a myoelectric and body-powered socket.  The patient utilizes her myoelectric socket for activities of daily living such as getting dressed, school, making food and two-hand holding of objects. The patient utilizes the body-powered socket during activities of daily living and during gymnastics and BMX biking.  It was noted that the patient did have radial head dislocation with tenderness over the radial head.  However, it was noted in the documentation that the patient was to wear her prosthesis for six months and then if pain was unbearable, surgery would be considered.  There was no clear rationale as to why the patient cannot continue to utilize the prostheses that have previously been provided as per her providers recommendations.  Therefore, the requested equipment 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 with sub-specialty certification in pediatric rehabilitation 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: Experimental/Investigational
Decision: Upheld

A 46-year-old male enrollee has requested cervical artificial intervertebral disc replacement for treatment of his medical condition. Findings:  Three physician reviewers found that In this patients case, the requested services are not likely to be superior over other treatment options.  This patient has degenerative disease at multiple levels, most severe at both the C5-6 and C6-7 levels, which require decompression and stabilization.  The current medical evidence has not established the superior effectiveness of the requested services in this clinical setting.  The medical literature indicates that delayed device-related complications may occur with cervical arthroplasty.  In sum, the requested cervical artificial intervertebral disc replacement is not likely to be of greater benefit than other treatment options, such as a cervical fusion, for this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old male enrollee has requested Prestige total disc arthroplasty for the treatment of his cervical disc protrusion and degeneration. Findings:  Three physician reviewers found that cervical disc arthroplasty, or replacement surgery, is a new implant and surgical procedure for the treatment of cervical disc disease. At this time, there is insufficient peer-reviewed literature reporting on the safety and efficacy of this procedure long-term, as well as compared to anterior cervical discectomy and fusion, the standard of care surgical procedure that has been done for decades.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 58-year-old female enrollee has requested authorization and coverage for removal of the enrollees left breast implant for treatment of the enrollees chest pains.Findings:  The physician reviewer found that based on the medical documentation provided for this review, it is not clear if the left breast implant is the source of her pain.  The patient does not have evidence of significant capsular contracture, infection or other process related to her implants that is the likely cause of her pain.  There is no medical indications for explantation of her implants. Therefore, it is unlikely that left breast implant removal would resolve or improve her functional complaint of pain. Although capsular contracture can cause pain and can be an indication for implant removal, the medical documentation does not support that this is present for this patient.  As such, implant removal would not likely address her functional complaint of pain. Therefore, left breast implant removal is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested procedure 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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.