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

The patients parent has requested authorization and coverage for Norditropin Flexpro or Nutropin AQ. Based on the medical records provided, this patient had no growth between 2016 and 2017, which suggests poor growth velocity. The patient had a bone age of 14 years at the chronologic age of 15 years five months, which gave him an estimated predicted adult height of 171.5 cm. This estimated predicted adult height is significantly below his midparental target height of 182 cm. He had a testicular volume of 4 mL prior to treatment with growth hormone (GH), which indicates delayed puberty could have contributed to his poor growth. However, the complete absence of any growth for five months suggests this patient has idiopathic short stature only partially attributed to his pubertal status. This patient had a good response to GH treatment, which suggests that his short stature is responding to Norditropin Flexpro GH therapy. Continuing GH therapy with Norditropin Flexpro is consistent with the current Pediatric Endocrine Society guidelines. Therefore, the requested Norditropin Flexpro 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 pediatrics with subspecialty certification in pediatric endocrinology 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 55-year-old female enrollee has requested Synvisc-One (orthovisc) injections for treatment of her osteoarthritis of the knees bilaterally. Findings:  The physician reviewer found that the peer reviewed medical literature has demonstrated that viscosupplementation is a useful tool for the treatment of patients with mild to moderate osteoarthritis of the knees. This medication is also approved by the Food and Drug Administration for treatment of knee osteoarthritis.  Clinical studies indicate that six-month intervals between injections are optimal.  In the case of this patient, it appears that she has previously responded well to viscosupplementation. The submitted records do not document that viscosupplementation was administered in the six months preceding the injections.  The injections with Synvisc-One in both of the patients knees was medically necessary for treatment of her osteoarthritis in both knees.
Appeal type: Urgent Care
Decision: Upheld

A 49-year-old female enrollee has requested hospitalization services for treatment of cervical decompression. Findings:  The physician reviewer found that the documentation submitted for review indicates that the patient contacted her surgeon on the specified date and was told to fly to Germany as soon as possible for surgical intervention. Although the patient was told to seek treatment, she did not arrive in Germany and receive care until the subsequent date. The patient did not seek immediate medical treatment on the day the symptoms presented. A three-day delay in seeking treatment is not consistent with the definition of an emergency medical condition. A prudent layperson who believed she was experiencing an emergency medical condition would have sought immediate medical attention at the time the symptoms presented. Additionally, while the patient states that her acute pareses in the right C7 myotome warranted emergency surgery, the extent of the pareses is not quantified or documented in the medical records. Furthermore, there is no documentation of acute myopathic findings on physical examination. Based upon the documentation provided, the hospital stay from the time frame specified did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Natesto for treatment of the enrollees hypogonadism. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The documentation provided for review does not show the patient has a contraindication or inadequate response to treatment with AndroGel. In addition, AndroGel prescribing information provides instructions of how AndroGel should be applied to minimize risk of skin-to-skin contact with another person. All told, Natesto has not been established as medically necessary for treatment of the patients hypogonadism. 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 endocrinology, diabetes and metabolism 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 has requested authorization and coverage for Amitiza. The records provided for review document that this patient has a history of chronic constipation. The provider reports that the patient has failed treatment with fiber as well as multiple laxatives, including magnesium hydroxide, which is an osmotic laxative. The American Gastroenterological Association (AGA) states that once conventional laxatives have failed, providers should consider advanced agents such as Linzess or Amitiza (Bharucha, et al.). In this case, multiple conventional laxatives were not effective, as well as Linzess, which is an advanced agent. Amitiza at the dose approved for chronic constipation, twice daily, was completely effective for the treatment of this patients constipation (Lacy, et al.; Wilson and Schey). For these reasons, Amitiza twice daily is medically necessary for the treatment of the patients chronic constipation. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Avastin treatment (10 mg injectable every two weeks) for treatment of her cervical cancer. Findings:  Two physician reviewers found that the combination of Afinitor and Avastin is not U.S. Food and Drug Administration (FDA) approved and it is not supported by the medical literature. Moreover, Afinitor and Avastin is not mentioned in the National Comprehensive Cancer Network (NCCN) guidelines as combination or alone. Clinical trials using mTOR inhibitors have largely been with temsirolimus rather than everolimus and have not shown significant response. There are a lack of published trials with the combination of everolimus and Avastin. The use of mTOR inhibitors in combination with other therapies is the subject of several ongoing clinical trials. 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. Credentials/Qualifications: Reviewer 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The 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

The patient is a 10-year-old male with autism. There is documentation the patient has learning disabilities. He is being treated with Buspar and Lexapro. It has been recommended the patient receive occupational therapy. The Health Plan has determined the requested therapy is not medically necessary for the patients condition.The submitted information indicates the patient has difficulty processing information and has difficulty with his fine motor skills. Patients such as this patient are likely to benefit from occupational therapy. It does not appear the patient is likely to benefit from other therapies. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should undergo a trial of occupational therapy for a three-month period.  If there are documented gains at the end of the three-month period, additional occupational therapy should be authorized.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patient has requested authorization and coverage for the use of a power scooter to perform one or more mobility related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community. Sund and colleagues report that the use of powered mobility devices, including power scooters, may contribute to mobility-related participation for patients with impaired mobility. This pertains to the subgroup of patients who cannot perform their daily activities or participate in community activities without a power scooter or wheelchair. In this case, a mobility assessment dated 3/29/22 reported that the patient is a functional ambulator within the home and limited with community distances. The patient is able to safely ambulate within the home with the assistance of a cane and is able to ambulate to a car and operate a car for medical appointments and community-related activities. The patient's upper and lower extremity range of motion was noted to be within functional limits and strength was noted as 4/5 bilaterally. The patient had a history of falls. The patient currently uses a cane, walker, manual wheelchair, and bath/shower chair. Given that the patient is a functional ambulator, does not require the use of a power scooter to perform the activities of daily living and participate in community activities, is able to propel a manual wheelchair, and has assistive devices to aid in community mobility and fall prevention, the requested equipment is not medically indicated. Therefore, the use of a power scooter to perform one or more mobility related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community, 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Mavyret 100-40 mg three tablets per day for eight weeks. 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related conditions. The patient's genotype could not be determined and the patient does not have cirrhosis and is reported to be to treatment-naive. Mavyret is effective for all genotypes of hepatitis C, and Mavyret for eight weeks is a first-line recommended regimen for non-cirrhotic patients with all genotypes of hepatitis C based on the results of a series of trials. Therefore, the genotype is not needed to determine which treatment regimen is appropriate for this patient, or whether the patient should be treated. Early treatment is warranted per the AASLD. Additionally, a study determined untreated hepatitis C can have several serious or devastating consequences, including the development of cirrhosis, hepatocellular carcinoma, lymphoma, cryoglobulinemia, and renal disease. For these reasons, the requested Mavyret 100-40 mg three tablets per day for eight weeks is supported as medically necessary 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 subspecialty 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:  An enrollee has requested Sovaldi and ribavirin for six months for treatment of her chronic hepatitis C virus genotype 3a.  Findings:  Three physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Disease Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all hepatitis C virus infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. The goal of treatment of hepatitis C virus infected persons is to reduce liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure as evidenced by an SVR. Thus, the requested Sovaldi and ribavirin for six months are medically necessary for treatment of this patients chronic hepatitis C virus infection. Final Result: Three reviewers determined that the requested medications are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sacroiliac (SI) joint fusion. According to the coverage criteria by the International Society for the Advancement of Spine Surgery (ISASS), the requested SI joint fusion is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient presents with significant SI joint pain and has failed to respond to at least six months of non-surgical conservative therapy. However, the patients SI joint pain has not been confirmed with at least three physical examination maneuvers that stress the SI joint and cause the patients typical pain such as distraction test, compression test, thigh thrust and FABER test. In this case, there is insufficient evidence of adequate documentation of three physical examination maneuvers demonstrating SI joint pain to warrant the procedure. Therefore, by the medical literature the patient does not meet the current ISASS criteria for a SI joint fusion.Findings:  Three physician reviewers found the requested SI joint fusion 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 SI joint fusion is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopedic surgery and are actively practicing. The 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: Urgent Care
Decision: Upheld

A 42-year-old male enrollee has requested for emergency services required on an emergent basis. Findings:  The physician reviewer found that this patient had been suffering from hemorrhoids for a year according to his statement.He was not experiencing an acute hemorrhage from his hemorrhoid. The hemorrhoids had not suddenly become thrombosed or ulcerated. Since the patient had already been evaluated for his symptoms, had already been prescribed medication, and there was no acute change in his condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested magnetic resonance imaging (MRI) of the left breast for evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  In the last several years, there has been significant growth in the use of breast MRI.  Breast MRI has an important role in both screening and diagnostic settings.  However, from a screening perspective, there is no indication that this patient meets the criteria for being at high-risk for developing breast cancer, as defined as having a 20-25% likelihood of developing the disease.  MRI studies of the breast are highly sensitive but have a relatively low level of specificity.  The literature consistently does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound.  This patient has had stable mammograms, which is probably the best indication that she does not have tumor.  The most valuable tool in interpreting a mammogram is a comparison with an older mammogram, especially when there are no palpable masses.  There is a lack of evidence supporting the use of MRI as a surveillance tool rather than conventional mammography.  This patient reports severe discomfort in her left breast.  Breast pain is rarely associated with breast cancer, especially without a recognizable mass.  In this patients case, there is no reason to doubt the accuracy of the mammogram.  In conclusion, there is there is insufficient data to support the requested services in this patients case.  All told, the requested MRI of the left breast is not medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that the requested services are 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 diagnostic radiology 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 40-year-old male has requested coverage for a right sport knee brace for treatment of his status post anterior cruciate ligament reconstruction.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested equipment in this patients case.  This patient is status post right knee arthroscopy, anterior cruciate ligament reconstruction with patellar tendon autograft and removal of loose body and hardware.  Following which, his neurovascular functions were intact, and motion was from 5 degrees to 90 degrees.  The current medical evidence does not support the use of the requested knee brace in this clinical situation.  Although braces are often prescribed for use after anterior cruciate ligament reconstruction, evidence to support brace use is lacking.  There is a lack of evidence indicating that brace use affects pain, range of motion, graft stability or protection from subsequent injury.  The use of prophylactic braces to prevent injury in contact sports has not been shown to be of value.  Additionally, the use of prophylactic braces has not been shown to be effective in postoperative rehabilitation following anterior cruciate ligament surgery.  All told, the requested right sport knee brace is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 22-year-old female enrollee has requested for residential treatment for treatment of her bulimia nervosa and major depressive disorder. Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings are thought to offer optimization of treatment gains.  Per American Psychiatric Association guidelines, when determining the appropriate level of care, the patients overall physical condition, psychology, behaviors, and social circumstances should be considered.  The current medical evidence supports residential level of care in this clinical setting.  This patient has failed a less restrictive treatment setting.  Based upon her persistent symptomatologies, negative schemas, family system issues, and psychosocial stressors, residential treatment is medically necessary.  All told, residential treatment is medically indicated for the treatment of this patient.