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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Gel-One injection. Findings: The submitted documentation supports the medical necessity of the requested medication. A study conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. There is no maximum amount of injections established by high-quality scientific evidence. This patient presents with significant right knee pain that is limiting his activities of daily living. Reasonable conservative treatment, including medications and activity modification, have failed to provide adequate symptom relief. Prior viscosupplementation has been performed in the past, with significant relief allowing for resumption of physical activity. Per the records, Supartz injections in 2008 and Synvisc injections in 2013 resulted in significant relief. The medical literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. This patient presents with significant right knee pain that is limiting his activities of daily living. Therefore, the requested Gel-One injection is 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test performed for evaluation of her pregnancy at advanced maternal age.  Findings:  Three physician reviewers found that the American College of Obstetrics and Gynecology (ACOG) recommends patients undergo non-invasive prenatal testing, especially in the high risk setting. ACOG endorses the discussion and use of non-invasive prenatal testing in this patient population. In this case, the gene test performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in obstetrics and gynecology 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: Medical Necessity
Decision: Upheld

A 36-year-old female enrollee requested authorization and coverage of orthotripsy for the treatment of plantar fasciitis.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested disc replacement and hybrid spinal repair (artificial disc replacement and spinal fusion) for medical treatment of his back pain.  Findings:  The physician reviewer found that there is no documentation of a recent physical examination of the lumbar spine. There was no documentation of a significant functional deficit. In addition, there is no evidence of spinal instability to support the necessity for spinal fusion. Based on the clinical documentation submitted for review, a disc replacement and hybrid spinal repair (artificial disc replacement and spinal fusion) is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The enrollees parent is requesting authorization and coverage for early childhood partial hospitalization program services. The enrollee was diagnosed with autism. The enrollee demonstrates behavioral issues and a movement disorder. She was admitted to a partial hospitalization program. The enrollees mother reports the applied behavioral analysis therapy was not addressing her daughters skill needs at the level of care required for progress. She asserts that, after her daughters treatment in the partial hospitalization program, her daughters level of functioning dramatically increased. Literature shows early intensive behavioral intervention, a treatment based on the principles of applied behavior analysis, delivered for multiple years at an intensity of 20 to 40 hours per week, is one of the better-established treatments for autism spectrum disorder. Research shows treatment intensity and duration were both significant predictors of mastered learning objectives across treatment domains.Final Result: The reviewer determined that the requested services were medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old male enrollee has requested authorization and coverage for Humira 20mg injections for treatment of the enrollees polyarticular juvenile idiopathic arthritis. Findings:  The physician reviewer found that the standard of care in pediatric rheumatology is to switch to a second anti-TNF agent in the event of failure of the first agent.  Although clinical trials involving Humira have been conducted in children over four years of age, younger children were not included in the trials due to the difficulty of recruiting a sufficient number of patients in this age group.
Appeal type: Medical Necessity
Decision: Upheld

The mother of a 16-year-old female enrollee requested authorization and coverage of Rocephin IV therapy through homecare. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees possible Lyme disease.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees articulation disorder. Findings:  The physician reviewer found that this patient did not begin combining words until 28 months of age. He now speaks in short phrases and sentences. There is no documented neurological or developmental disorder as the cause for this patient's articulation disorder. However, this patient shows less than 50% intelligibility in an unknown context.  Roulstone and colleagues noted that children with an articulation disorder at this age are at risk for other learning disabilities later as a child.  They also documented that in this type of clinical scenario, improvement is not likely to occur without treatment regardless of other developmental delays.  In this patients case, the requested speech therapy is medically indicated for the treatment of his articulation disorder.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 53-year-old male with knee pain. The patient has undergone surgery, and has attempted treatment with medications and steroid injections. Hyalgan has been recommended by his provider. The Health Plan denied authorization for the requested therapy on the basis that Hyalgan is not medically necessary.The patient is an appropriate candidate for Hyalgan therapy. Anti-inflammatory medications and cortisone have failed to alleviate his pain. Studies have shown Hyalgan is clinically effective in this clinical setting. As such, it is likely that Hyalgan will be beneficial for this patient and it is the best alternative to surgery at this time. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for HP Acthar Gel 80 units/mL (2 x 5 vials), inject 80 units subcutaneous (SQ) every day for five days. The records provided for review support a diagnosis of relapsing remitting multiple sclerosis. The patient demonstrates left-sided lower extremity weakness with spasticity. The provider noted that there is intolerance to intravenous Solu-Medrol consisting of side effects of worsening fatigue, speech/swallowing difficulties, weakness, spasticity, disorientation and hallucinations. These effects are consistent with worsening of disease rather than drug effect. There is documentation that the patient has successfully received a five-day course of treatment with intravenous Solu-Medrol, with positive response. Acthar Gel, which is a depot version of steroid, is appropriate when there is difficulty obtaining intravenous access or inability to travel to an infusion center. The patient does not meet either of these two criteria. Therefore, the requested HP Acthar Gel 80 units/mL (2 x 5 vials), inject 80 units subcutaneous (SQ) every day for five days is not medically necessary for treatment of 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 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

DO NOT POST - DISPUTED TREATMENT CATEGORY BLANK.The parent of a three-year-old male enrollee has requested speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that People with autistic spectrum disorders (ASDs) have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services`(Myers and Johnson). Further, Turner and Stones report concluded that the total hours of speech therapy starting at age two was the most important factor in improved language at nine years of age. At age three, this autistic patient is an appropriate candidate for speech therapy. The American Speech-Language-Hearing Association white paper on autism states that speech therapy is necessary and ongoing until the patient can communicate appropriately in social circumstances. Taken together, these guidelines and recommendations demonstrate that speech therapy is medically necessary for this patient. Although this patient is severely impaired, two speech therapists have recommended speech therapy despite his developmental delays. While development of speech may be slow even with intensive speech therapy, the skills acquired through such therapy are necessary for this patient to develop communication skills.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Testopel pellets every six months. This patient has a history of hypogonadism. He has been treated with testosterone pellets, and his provider has monitored the patients testosterone levels. He has maintained mid normal testosterone levels with this therapy, with no adverse side effects. The Endocrine Society guidelines recommend testosterone therapy for men with symptomatic testosterone deficiency to induce and maintain secondary sex characteristics and correct symptoms of hypogonadism after discussing the potential benefits and risks of therapy. Testosterone pellets are a form of testosterone replacement therapy. The patients provider has been properly monitoring the efficacy and safety of this therapy. The current medical evidence supports the requested medication in this clinical setting. Therefore, Testopel pellets every six months are 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 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 mother of a three-year-old male enrollee is seeking occupational and speech therapy services for the treatment of the enrollees developmental delay. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that this patient has a serious neurological and psychological medical condition that requires treatment. Other patients with similar findings have improved significantly with occupational and speech therapy to the point where they are able to function in school and society. The patient is an appropriate candidate for the proposed services, which are likely to result in clinical improvement in his condition.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old female requested an abdominal and pelvic computed tomography (CT) scan.  The physician reviewer found that Uterine leiomyomas (fibroids or myomas) are the most common pelvic tumor in women. They are benign monoclonal tumors arising from the smooth muscle cells of the myometrium. They arise during reproductive age in women and typically present with symptoms of abnormal uterine bleeding or pelvic pain/pressure. Uterine fibroids may also have reproductive effects. The diagnosis of uterine sarcoma is based upon histological examination. Uterine sarcomas are most commonly diagnosed following myomectomy or hysterectomy for presumed leiomyomas. Surgery is the mainstay of therapy for leiomyomas. Hysterectomy is the definitive procedure, while myomectomy by various techniques is the alternative.There are no high quality data regarding the follow-up of fibroids in patients who are asymptomatic or who decline medical or surgical treatment. An initial imaging study, usually an ultrasound, is used to confirm that a pelvic mass is a fibroid and not an ovarian mass. After an initial evaluation, an annual pelvic exam is performed and, in patients with anemia or menorrhagia, a complete blood count. If symptoms or uterine size are increasing, further evaluation is indicated as well as patient counseling regarding treatment options. Preoperative and intraoperative findings are of limited value in estimating the likelihood that a mass is a uterine sarcoma. Additionally, there is no pelvic imaging modality that can reliably differentiate between benign leiomyomas and uterine sarcoma. Leiomyomas and uterine sarcomas appear similar, both are focal masses within the uterus and both often have central necrosis. Computed tomography does not reliably differentiate between leiomyomas and uterine sarcoma and therefore would be of no benefit in the diagnosis or treatment of this patient. The requested diagnostic test is not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting authorization and coverage for the medication, Vascepa, 1 GM. The enrollee has a medical history of hypertriglyceridemia and pre-diabetes. The enrollee reported adhering to a low carbohydrate diet. The provider prescribed Vascepa, 1 gram capsules. The enrollee stated that Vascepa is necessary as his triglycerides are still high; despite taking fenofibrate for four years. The recommendation for the use of omega-3 fatty acids, such as Vascepa, is that they should be used only in the setting of persistently elevated severe hypertriglyceridemia; greater than 500 milligrams per deciliter. The enrollees triglyceride levels are lower than 500 milligrams per deciliter, which is the threshold for treatment with triglyceride-lowering therapy, such as Vascepa.  Additionally, the provider reported that this enrollee is not taking the prescribed fenofibrate.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in family 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 27-year-old female enrollee has requested a comfort carrier transfer sling for medical treatment of her quadriplegia secondary to spinal cord tumor.  Findings:  The physician reviewer found that the patient has profound deficits in mobility and requires a Hoyer Lift for transfers. A comfort carrier device has been requested under the rationale that it is needed for emergency transport. It is a device, not dissimilar to the sling on a patient transfer system such as a Hoyer Lift, that is made of canvas or canvas-like tarp material, which has handles so that multiple caregivers can manually transfer or transport a dependent in situations such as an inaccessible environment or in an emergency situation. However, the requested comfort carrier device is not necessary or appropriate for this patients accomplishment of basic mobility related activities of daily living. Basic mobility related activities of daily living needs are more appropriately met with the Hoyer Lift and its sling. Emergency transport needs can be met with other means. Overall, there is no evidence that use of the proposed comfort carrier device would result in improved outcomes over other alternatives in the event of an emergency. Notably, with respect to dependent level transfers, the comfort carrier requires at least two physically fit persons to use for a transfer, whereas a manual transfer of a person who is totally dependent for transfers can be accomplished by only one physically fit unskilled person with some minimal training. Further, transport of a dependent person in a comfort carrier over an extended distance would also subject the transporters and dependent to risk of injury. For these reasons, the requested comfort carrier transfer sling is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 54-year-old female with a diagnosis of hydrocephalus based on MRI results. The patient has cognitive complaints. She has been evaluated by multiple providers including two neurosurgeons who had divergent opinions regarding the potential benefits of VP shunt placement. The patient has requested authorization and coverage for a referral to another neurosurgeon for evaluation of the need for further testing prior to VP shunt placement. The Health Plan has denied this request indicating that the requested referral is not medically necessary for treatment of the patients enlarged ventricles.The patient has a complex medical history. One of the examining neurosurgeons has recommended the patient undergo surgical intervention. Based upon the information provided, it is not clear VP shunt placement will resolve the patients symptoms. Evaluation by another neurosurgeon is medically reasonable and appropriate prior to surgical intervention. Given the lack of objective evidence demonstrating VP shunt placement is the most appropriate treatment option for this patient, further consultation is required and should be authorized. Therefore, I have determined that the requested referral is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Urgent Care
Decision: Upheld

A 62-year-old female enrollee has requested for excision of skin lesions for treatment of her skin cancer.    Findings:  The physician reviewer found that there was no acute change in her condition, and no emergent medical intervention was required. This patients symptoms do not meet the prudent layperson criteria for an emergency.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested reimbursement for genetic testing. Although antiphospholipid syndrome has been associated with early pregnancy loss, routine testing for other thrombophilias is not recommended by the American College of Obstetricians and Gynecologists (ACOG). In addition, this patient does not have a reported personal or family history of clotting disorders to warrant testing for thrombophilias. According to the ACOG practice bulletin, no work-up generally is recommended until after the second consecutive clinical early pregnancy loss. Specifically, ACOG noted that maternal or fetal chromosomal analyses or testing for inherited thrombophilias are not recommended routinely after one early pregnancy loss. Further, from the American Society for Reproductive Medicine (ASRM), routine testing of women with recurrent pregnancy loss for inherited thrombophilias is not recommended. Accordingly, the genetic testing was not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the genetic testing was not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Final Result: The reviewers determined that the genetic testing was not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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.