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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for speech therapy services. Based on the available documentation of the patient's lack of progress, and in line with multiple professional recommendations, the continuation of speech therapy is not medically necessary at this time. Any progress made over two years of speech therapy would manifest in the standardized test scores. In this case, scores were lower at the second testing almost two years after initial testing, indicating that progress had not been made. The National Autism Center highlights ABA therapy as the most effective evidence-based treatment for autism. In this case, the patient appears to have made several gains through this service format. According to researchers, speech therapy is not medically necessary as the speech therapy in this case is not meeting the essential health needs of the patient. Therefore, the requested speech therapy services are 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 psychology, is a board certified behavioral analyst, 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 Emgality. According to the American Headache Society (AHS), there are four injectable preventive therapies available for the treatment of migraine including Botox and three monoclonal antibody (mAb) targeting calcitonin gene-related peptide (CGRP) agents, such as Emgality, or targeting the CGRP receptor. Emgality is U.S. Food and Drug Administration (FDA) approved for episodic and chronic migraine. Emgality 120 mg is for monthly use following an initial loading dose of 240 mg. In this case, the patient has a history of chronic migraines that have not adequately responded to oral preventative medications. The use of Botox has been effective in reducing the number of headache days though her headaches have recently become more severe. The addition of Emgality has further diminished the severity and number of headache days. Per the AHS statement, it is appropriate for this patient to be treated with an anti-CGRP mAb she has chronic migraine refractory to standard preventatives. As noted in the AHS statement, after three months of treatment with an anti-CGRP mAb, a patient should continue treatment if there is a reduction in mean monthly headache days of 50% relative to pretreatment baseline and other documented benefits. Per the AHS consensus statement, anti-CGRP mAbs (such as Emgality) lack hepatic metabolism and renal clearance and therefore avoid interactions with concomitant drugs. Anti-CGRP mAbs may be added to or used in conjunction with other oral or injectable preventive treatments for migraine. In the study by Robbins, patients managed with a combination of Botox and a CGRP inhibitor (such as Emgality) improved clinically 40 to 80% over baseline, and no interactions or problems were observed with the combination of medications. Per the medical evidence, combination therapy with Emgality and Botox can be safe and effective. In this case, the patient experienced a documented reduction of migraines from 45 of 90 days to 13 of 90 days, with improved severity, and less need for rescue medication. All told, the requested Emgality is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that the enrollee requested authorization and coverage for a Synvisc-One/Hyaluronan Injection. The Health Plan has denied this request indicating that the requested injection is not medically necessary for treatment of the patients right knee primary osteoarthritis. The submitted documentation supports the medical necessity of the requested Synvisc-One/Hyaluronan Injection. Current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. As researchers noted, there is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting, as compared with intraarticular corticosteroids. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, a reduction in use of concomitant analgesia by up to 50 percent, and suggests that there may be a delay in the need for total knee replacement of around 2 years. Another research performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Their review found that the current highest level of evidence suggests that an intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for up to 26 weeks. Intra-articular hyaluronic acid has a good safety profile, and its use should be considered in patients with knee osteoarthritis. There is sufficient support for the requested service in this clinical setting. Therefore, the requested Synvisc-One/Hyaluronan Injection is medically necessary to treat the patients medical condition at this time.Final Result: The reviewer determined that the requested Synvisc-One/Hyaluronan Injection 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 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:  The parent of an enrollee has requested authorization and coverage for Xeljanz 5 mg tablets.Xeljanz (tofacitinib) is well-tolerated in the studies to date and is effective in patients who are refractory or no longer respond to other therapies. In an article by Strazzulla and colleagues, an algorithm was published that recommended immunotherapy or Janus kinase (JAK) inhibitors with or without intralesional Kenalog for scalp involvement greater than 50%. In this case, the patient presents with hair loss. At the time of initial presentation, the patient had one patch that progressed to involve 80% of his scalp hair. The patients prior treatments include intralesional Kenalog and minoxidil. After a course of prednisone, the patients scalp hair grew back. By April 2021, the patient had lost about 40-50% of scalp hair again. Given the recurrence was about 50% involvement, the patients disease is refractory to traditional treatments. The requested medication is effective in patients who are not responding to traditional therapies. Thus, Xeljanz 5 mg tablets are medically necessary for treatment of the patients medical condition.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: Upheld

A 49-year-old female enrollee requested authorization and coverage of uterine artery embolization. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees uterine fibroids.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old male enrollee has requested 36 hours per week of applied behavioral analysis (ABA) therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that this patients provider has carefully documented the patients treatment goals and specific steps demonstrating progress. In general, patients with ASD are often treated with ABA therapy. Many of the patients treatment providers are recommending ABA therapy for 36 hours per week to fully address the individual needs of the patient. This treatment plan is consistent with the relevant medical literature which supports the efficacy of ABA therapy for young patients with ASD. As noted by Foxx in his 2008 article, the most productive services are intensive and individualized to the patients needs. As the patients April 2010 progress report illustrates that he continues to have documented deficits related to ASD, yet has achieved many milestones toward his overall progress, the requested ABA services are clinically indicated and medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested for chemical dependency residential detoxification level of care  for treatment of her behavioral health condition. Findings:  The physician reviewer found that the evidence provided does not support this level of intensity of service. The patients past history noted alcohol dependence with an increase in use two months prior to admission to the residential detoxification program. The mental status exam (MSE) performed on admission indicated that the patients judgment was minimally impaired, she was cooperative, there were no major health issues and no major findings on MSE. The patient reported a history of anxiety. However, the records do not reflect severe co-morbid conditions and there was no major risk of self-harm. Thus, based on a review of the medical records and based on Level of Care Utilization System placement criteria and American Psychiatric Association practice guidelines, the patient would have been an appropriate candidate for a less restrictive level of care for the dates in question.
Appeal type: Urgent Care
Decision: Overturned

A 55-year-old male enrollee requested ambulance transportation services for emergency services as well as to and from regularly scheduled hemodialysis medical treatments.  Findings:  The physician reviewer found that review of the submitted medical records demonstrates that the patient was transported to the hospital on more than one occasion as he was experiencing an acute change in his medical condition that warranted immediate medical attention. Thus, ambulance transport services on those occasions met criteria for ambulance transportation. A prudent layperson would seek immediate medical attention under these circumstances.  On other occasions, the patient utilized ambulance transportation services to and from routine, scheduled, outpatient hemodialysis treatments. The patient was not bedridden and in most instances was able to ambulate to the gurney. During the first transport the patients systolic blood pressure was in the 90s. He was not tachycardic or symptomatic. The remainder of the transport logs all record normal blood pressures with systolic blood pressures above 100. The patient did not require any medical intervention by paramedics. He was not oxygen dependent. In none of the cases was the 911 system activated to transport the patient to the nearest hospital for acute symptoms of such severity that a prudent layperson would believe his life to be in jeopardy. All told, not all ambulance transportation services met prudent layperson criteria for emergency care and the patient could have been safely transported to and from hemodialysis treatment by other means.  Thus, a portion of the services at issue met prudent layperson criteria for emergency care.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a five-year-old female enrollee has requested for occupational therapyn treatment of her autism.  Findings:  Two physician reviewers found that occupational therapy is neither experimental nor investigational. It is standard of care for children such as the patient, who have difficulties that impact development of the occupations of childhood. Sensory integration therapy is one technique that a skilled therapist can use to facilitate positive change in a child with global deficits. Many techniques may be necessary when dealing with such a broad range of difficulties. The fact that this patient has shown progress with occupational therapy supports the appropriateness of treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old female enrollee has requested for lipoprotein diagnostic testing for evaluation of her risk for cardiovascular disease.   Findings:  Three physician reviewers found that there is no documentation of coronary artery disease or mention of other cardiac risk factors in the records. As discussed by Brunzell, the American Diabetes Association and the American College of Cardiology Foundation guidelines for the diagnosis and management of dyslipidemia and cardiovascular risk currently to not recommend routine performance of specialized lipid-associated tests. The author notes that modifications to treatment based on the results of routine screening with specialized lipid tests has not been shown to improve outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. The only circumstance where specialized lipid testing may be considered appropriate is in selected cases of secondary prevention where standard risk factors are not present to a sufficient degree to explain cardiovascular event occurrence.
Appeal type: Experimental/Investigational
Decision: Upheld

Findings:  The physician reviewer found that  An enrollee has requested authorization and coverage for Lumakras. In this case, the patient has disease progression despite an aggressive clinical course on standard folinic acid, fluorouracil, and oxaliplatin (FOLFOX) and folinic acid/fluorouracil/irinotecan (FOLFIRI). KRAS is one of the most frequently mutated oncogenes in colorectal cancer. Sotorasib (brand name Lumakras) is an inhibitor of the mutated KRAS proteins. Blair notes that the U.S. Food and Drug Administration (FDA) approves the use of sotorasib in adult patients with KRAS G12C-mutated locally advanced or metastatic NSCLC who have received at least one prior systemic therapy. The drug is not currently approved by the FDA for the treatment of colorectal cancer. In a phase 2 clinical trial, Hong and colleagues found that the drug had encouraging activity in heavily pre-treated patients with advanced solid tumors including non-small cell lung cancer (NSCLC). The authors noted that in a study of the efficacy of sotorasib on a subgroup of 42 patients with colorectal cancer, 7.1% (or 3 patients) had a confirmed response, and 73.8% (or 31 patients) had disease control. While studies are ongoing, a response rate of 7% does not suggest a significant clinical response to sotorasib in the context of colorectal cancer. In this case, the patient has a confirmed targetable mutation in KRAS, and it makes logical sense to use this new drug based on its mechanism of action. At this point, however, the clinical evidence for the use of sotorasib in colorectal cancer is very preliminary and does not justify its routine use. Therefore, Lumakras is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Lumakras is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old female enrollee has requested reimbursement for monopolar capacitive radiofrequency procedure for treatment of the enrollees sacroiliitis.  Findings:  Two physician reviewers found that the patient has sacroiliac (SI) joint pain. The limited records indicate that she has failed traditional treatments including physical therapy, medications, injections, and lifestyle modifications. She was treated with monopolar capacitive coupled radiofrequency. The patient has requested reimbursement for the monopolar capacitive radiofrequency procedure. Per standard of care guidelines through American Society of Interventional Pain Physicians (ASIPP), the use of radiofrequency ablation for SI joint pain is reasonable with either a cooled invasive lesioning probe or a bipolar lesioning probe. The guidelines indicate the procedure is supported by well documented and controlled trials demonstrating improvement in patients pain due to the posterior SI joint capsule and joint dysfunction. However, there is a paucity of documentation and minimal literature for use of the monopolar capacitive coupled radiofrequency for SI joint pain. Monopolar capacitive radiofrequency is generally used in tendonitis and cosmetic procedures. Overall, there is no quality controlled trial to show joint pain or SI dysfunction is an indication for monopolar capacitive radiofrequency. Further, this patients records do not clearly document previous treatments and outcomes, as well as diagnostic work-up to diagnose and treat her SI joint pain. In the absence of a contraindication to well accepted forms of radiofrequency ablation, the use of monopolar capacitive radiofrequency was not likely to be more beneficial in treating this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of the enrollee has requested authorization and coverage for 35 hours of applied behavioral analysis (ABA) services per week. ABA therapy covers a variety of methods concerned with the application of behavioral science to socially important functions, particularly in patients with intellectual disabilities (Virues-Ortega). Common features of ABA based therapies include the objective measurement of behavior, structured control of the environment, and the implementation of procedures based on scientifically established principles of behavior. The Behavior Analyst Certification Board (BACB) state that, comprehensive treatment often involves an intensity level of 30-40 hours of one-to-one direct treatment to the client per week, not including caregiver training, supervision, and other needed services. In the medical literature, Orinstein and colleagues reviewed the intensity of ABA therapy required for optimal outcomes in children with autism spectrum disorder and found no correlation between the number of hours provided per week and outcomes. The authors noted that the age at which ABA therapy was started and duration of treatment were correlated with patient outcome. Based on the available documentation, the provision of direct ABA therapy hours to 28 per week as recommended by the Health Plan is appropriate. The patient has been making progress in most areas, and decreasing direct ABA hours is appropriate. All told, the requested 35 hours of ABA services per week are 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 pediatrics and neurology with special qualification in pediatric 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Entresto 49 mg - 51 mg tablet. Findings:  The physician reviewer found that the documentation provided does not support the requested medication in this clinical setting. Based on the records provided, the patient has mitral valve repair and a cardiomyopathy. Left ventricular ejection fractions are reported at greater than 35% (most recently 41%). Additionally, the documentation does not support any ongoing heart failure symptoms or findings of heart failure on physical examination. In this circumstance, with most recent ejection fraction of greater than 40% and no documented ongoing signs or symptoms of congestive heart failure, treatment with Entresto is not medically indicated and not considered standard accepted practice. Entresto is considered medically appropriate in patients with ongoing New York Heart Association class II or class III congestive heart failure and left ventricle ejection fraction at 40%. The documentation provided does not support the clinical criteria for Entresto. For these reasons, Entresto 49 mg - 51 mg is not medically necessary for treatment of this patients medical condition. 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.