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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz 5 mg tablet. Review of the submitted evidence demonstrates that the requested Xeljanz 5 mg tablet is medically necessary for treatment of the patients medical condition. In this case, the patient has seronegative rheumatoid arthritis, Sjogren's syndrome and a positive ANA. The submitted documentation demonstrates the patient has failed methotrexate and hydroxychloroquine. Further, there is evidence the patient has previously done well with Xeljanz with no evidence of synovitis. Given the patients history of positive ANA, a tumor necrosis factor inhibitor (TNFi) such as Enbrel or Humira would not be recommended. Therefore, the requested Xeljanz 5 mg tablet is medically necessary.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 rheumatology 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 sofosbuvir and daclatasvir for treatment of his hepatitis C.  Two physician reviewers found that per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, the medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  Urgent initiation of treatment is recommended for some patients, such as those with advanced fibrosis or compensated cirrhosis.  This patient has failed previous interferon-based treatment and later failed sofosbuvir and ribavirin.  The current medical evidence supports the requested treatment regimen of sofosbuvir and daclatasvir in this clinical setting.  In this patients case, urgent initiation of treatment is indicated, as he has an extrahepatic manifestation of hepatitis C, namely large B-cell non-Hodgkins lymphoma.  All told, sofosbuvir and daclatasvir is medically indicated for the treatment of this patient.  Final Result: Two reviewers 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: All 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: Upheld

A 42-year-old female enrollee has requested for Simponi injections for treatment of her hidradenitis suppurativa. Findings:  The physician reviewer found that there is currently no evidence in the peer-reviewed literature that Simponi is effective in the treatment of hidradenitis suppurativa. Given the lack of support in the medical literature for the efficacy of the requested medication and limited documentation regarding the severity of the patients disease, combined with the lack of evidence that the patient has exhausted conventional therapies, the medical necessity of Simponi injections has not been established.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a five-year-old male with a diagnosis of speech and language delay (expressive and receptive).  He also has a diagnosis of auditory processing disorder.  He has been receiving speech therapy since July 2003.  The record provided for review includes an evaluation from January 2005 and daily progress notes from September 2004 through May 2005.  The Health Plan has denied coverage for speech therapy provided from January 2005 through May 2005 based upon a determination that it was not medically necessary.The January progress report indicates the patient was meeting all goals at that time.  However, the daily notes only document the treatment that was provided during the session and do not address functional goals.  Additionally, the therapist does not perform standardized testing to show progress toward specific goals.  In the January progress report the therapist typically reports that the goal has been met and describes the patients current level of functioning for that goal.  The progress report does not compare the current functional level with the functional level at the beginning of that evaluation period.  As a whole, the progress report only reflects the current functional level, and does not quantify the amount of change or improvement over the specified time period. For example: Goal #1 is to increase the number of communication circles in which (the patient) can participate. The progress to goal is described as (the patient) is now participating in up to 5  10 circles of communication during highly motivating activities.  There is no statement comparing the number of communication circles the patient participated in at the beginning of the evaluation period with the number of communication circles he participated in at the end of the evaluation period.  Based upon the inadequate documentation of gains, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for onabotulinum toxin A injections. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees migraines. At issue in this case is whether the requested onabotulinum toxin A injections are medically necessary for treatment of the enrollees medical condition. A study concluded that in chronic migraines, botulinum toxin type A might reduce the number of migraine days per month by two days. The guidelines define chronic migraine as 15 days or more per month with a headache lasting four hours or more. The patient meets this definition. The patient has failed other conservative treatments. He is taking sertraline and gabapentin and frequency has improved greater than seven days from use of onabotulinum toxin A injections every 3 months for the past year. Therefore, the requested medication is medically necessary.Final Result: The reviewer determined that the requested treatment 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 anesthesiology with subspecialty certification in pain 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: Overturned

A 60-year-old male enrollee has requested CyberKnife stereotactic radiosurgery (or intensity modulated radiation therapy, in the alternative) for treatment of his hepatocellular carcinoma. Findings:  Two physician reviewers found that the patient was seen at a center of excellence by an international expert on the use of stereotactic radiosurgery (SRS) for brain and spine tumors. The records have demonstrated that he has a solitary site of residual metastatic disease at present. He had 1 known site of disease over the past 15 months, and has done well with aggressive therapy. In general, conventional radiation for treatment of spinal tumors is difficult to control given the radiation sensitivity of the adjacent spinal cord, preventing doses that are likely to provide a sustained response. For this reasons, non-conventional techniques are required to dose escalate the tumor while not overdosing the spinal cord. Thus, either SRS with CyberKnife or IMRT are reasonable, but SRS with CyberKnife is likely to be more effective and would entail fewer treatment sessions than with IMRT. The references report an approximated 90% success rates in local control and pain relief, and neurologic improvement is often appreciated. This patient will most likely experience a similar positive outcome if treated. Given the above, SRS with CyberKnife technology for treatment of this patients spinal lesion should not be categorized as experimental or investigational and should be approved.
Appeal type: Experimental/Investigational
Decision: Upheld

A 29-year-old male enrollee has requested for transcranial magnetic stimulation (TMS) for treatment of the his behavioral health condition.   Findings:  Two physician reviewers found that current scientific data does not support the use of TMS therapy in this patients case. The medical literature indicates that there is insufficient evidence in support of its efficacy to warrant use in standard practice. Other studies have shown that patients with psychotic depression do not respond well to TMS, and hence it is likely to be less effective than ECT, which is the treatment of choice of the patients condition. Although the patient complains of memory loss, this effect is likely to be transient and can be mitigated by unilateral electrode placement.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested urinary tumor marker (FISH Assay) testing for medical evaluation of her medical condition.  Findings:  Three physician reviewers found that the peer-reviewed literature does not support the use of UroVysion in this clinical setting. UroVysion is a fluorescence in situ hybridization (FISH) assay that detects bladder cancer in urine specimens. At this time, cystoscopy and cytology, and possible biopsy, is indicated in this clinical setting regardless of the results of FISH testing. In sum, the testing at issue was not likely to be more beneficial for evaluation than standard diagnostic studies in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old female has requested coverage for past residential treatment services for treatment of her behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, at the time of discharge from the wilderness program and admission to RTC, the patient no longer met criteria for RTC level of care. The patient was noted to have developed the ability to identify her risk factors for relapse as well as acquiring coping skills to prevent relapse. Moreover, the patient showed a positive attitude toward maintaining sobriety. According to the American Psychiatric Association (APA) and Milliman Care Guidelines, this patient was a candidate for a less restrictive level of care during the period under review. For these reasons, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 31-year-old female enrollee has requested magnetic resonance imaging (MRI) for evaluation of her spinal cord injury.  Findings:  The physician reviewer found that this patient has a documented problem in her cervical cord but does not have a documented indication for the requested MRI based on the available records. A detailed neurosurgical evaluation is needed prior to consideration of further imaging. This patient does not have progressive neurological deficits so there is no emergent reason to proceed with MRI of the cervical spine without direction from a qualified spinal specialist. For these reasons, the requested MRI is not supported as medically necessary for evaluation and treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Rituxan infusion treatment. Standard therapy for relapsing remitting multiple sclerosis includes a number of disease-modifying therapy (DMT) options approved by the Food and Drug Administration (FDA) for the long-term treatment of relapsing remitting multiple sclerosis. Rituxan is a monoclonal antibody directed against the CD20 antigen on B-lymphocytes that causes B cell reduction. In an observational study of 494 patients diagnosed with relapsing remitting multiple sclerosis, Rituxan was associated with a lower discontinuation rate compared with other disease modifying therapies. Per the American Academy of Neurology (AAN) practice guidelines, patients with multiple sclerosis who are stable on DMT should continue their current DMT unless the patient and physician decide a trial off therapy is warranted. In this case, the patient has multiple sclerosis with evidence of lesions in the brain and cervical spine cord and JC virus positivity. Based on the current peer-reviewed medical literature, Rituxan is comparable to other disease modifying therapies. This patient has cervical cord lesions which can cause disability if her disease progresses. She has been treated with Rituxan for the past three years. The records document that the patient has been stable with no reported clinical progression of disease while on Rituxan. For these reasons, the requested Rituxan infusion treatment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Rituxan infusion treatment is 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 services 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: Physician reviewers 1, 2, and 3 are board certified in neurology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that Transcranial magnetic stimulation is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder.  Transcranial magnetic stimulation tends to be very well-tolerated, with fewer barriers and side effects than electroconvulsive therapy.  The American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial.  Although transcranial magnetic stimulation has not been adequately studied for treatment of substance use disorders and obsessive compulsive disorder, the patients affective illness is not disputed and there is no contraindication for transcranial magnetic stimulation because of said diagnoses, which happen to be questionable in this case.  The patient has remained symptomatic despite several antidepressant medication trials, complex pharmacotherapy, and multiple non-pharmacologic interventions. Transcranial magnetic stimulation is a medically appropriate treatment which is reasonably expected to improve the patients condition and prevent a more serious episode of illness.  Therefore, transcranial magnetic stimulation is medically indicated for the 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 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 a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 43-year-old female enrollee has requested the Flexitouch Lymphatic Pump for treatment of her lipedema with lipo-lymphedema. Findings:  Two physician reviewers found that the requested equipment is not likely to be of greater benefit than other available treatment options in this patients case.  The current medical evidence has not demonstrated that the Flexitouch Lymphatic Pump has a clinical benefit beyond existing treatments.  There is support for other treatment approaches for chronic lymphedema, including weight training, microsurgery, and low-level laser light treatment.  In sum, there is a lack of data from controlled prospective trials supporting the superior efficacy of the requested Flexitouch Lymphatic Pump.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 12-year-old male enrollee has requested Vyvanse 80 mg/day for the treatment of the enrollees attention deficit hyperactivity disorder (ADHD). Findings:  The physician reviewer found that the concept that this patient may be a rapid metabolizer of his medications is a well-documented concept in the literature, especially for his age group as prepubescent children have efficient livers (see Schatzberg). This generally allows them to metabolize drugs rapidly and enables them to tolerate somewhat higher doses of psychiatric drugs per unit of weight than adults. This is a possible explanation as to why he has had numerous medication trials in the past, and has required high doses of each of the medications he has tried. The literature supports the fact that 70-80% of children with ADHD will respond to one stimulant medication, and 85-90% will respond when tried on a second stimulant medication. This patient has tried more than 10 medications for his ADHD, which puts him in a very small minority of patients; his illness is clearly severe. Vyvanse has a novel delivery concept in that it is a therapeutically inactive molecule until it is hydrolyzed by endogenous enzymes to l-lysine, an amino acid, and d-amphetamine, which is responsible for the therapeutic effect. This is a possible reason as to why this medication is effective for him. The active medication is getting to his liver at a slower rate because Vyvanse's conversion to d-amphetamine is dependent on enzymatic conversions that occur in the gastrointestinal tract, and are not necessarily proportional to liver metabolism rates. Vyvanse is novel only in its delivery method.  It is converted into its active medication d-amphetamine throughout the day in order to have therapeutic effect. D-amphetamine has been used for many years for the treatment of ADHD, it is not a new treatment. Due to the fact that this patient has tried and failed numerous medications in the past, it is medically appropriate to treat him with a medication dosage above that recommended by the FDA.  Per Pliszka, `the AACAP [American Academy of Child and Adolescent Psychiatrists] has also issued specific parameters for the use of stimulant medicationsThese doses represent guidelines; with careful clinical monitoring, these doses may be exceeded in individual cases.` It is clear according to the literature that other stimulant medications do have published `off label` maximum dosages that exceed current FDA guidelines, and clinically this can be extrapolated to Vyvanse as well. In conclusion, Vyvanse at the 80 mg/day dosage is medically necessary to treat this patient's ADHD. He has been stable on this dose for several months, and has been tolerating it well.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for three sessions per week of speech therapy and three sessions per week of occupational therapy, or in the alternative fewer sessions per week of speech therapy and occupational therapy. Functional impairments due to acutely acquired brain insults improve with time and are also amenable to rehabilitation interventions. Skilled therapy services are appropriate following an acute brain injury to promote recovery, maximize function, transition patients to an independent program when feasible, or to train caregivers for supervising a patients convalescence in the community (Lee, et al.). Deficits can persist, particularly in the setting of severe brain insults, including cognitive deficits and behavioral manifestations (Brasure, et al.; Smania, et al.). However, the benefits of long-term cognitive rehabilitation in this clinical setting remain unclear (Chung, et al.; Eshel, et al.). The records provided for review document that this patient sustained a traumatic brain injury in a motor vehicle accident in October 2020. She underwent extensive inpatient level care including acute inpatient rehabilitation, where she made significant functional progress for her with severe impairments. She was discharged home where she requires some supervision for tasks such as bathing. The patient has lingering higher level cognitive deficits and judgment impairments consistent with the nature of her injuries, which included frontal lobe intraparenchymal injury. The patients speech and functional memory are otherwise functional. While impairments and functional deficits persist, there is no reasonable expectation of improvement in outcomes with further formal speech and occupational therapies. The patient has maximized the benefit that she is expected to obtain from these types of services. For these reasons, the requested three sessions per week of speech therapy and three sessions per week of occupational therapy, or in the alternative fewer sessions per week of speech therapy and occupational therapy, are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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 59-year-old female enrollee requested authorization and coverage of intravenous zometa for the treatment of osteoporosis.  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 medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old male enrollee has requested uvulopalatopharyngoplasty (UPPP) for the treatment of his sleep apnea. Findings:  Three physician reviewers found that the indication for the UPPP is generally agreed to be a RDI/AHI of greater than 20 events per hour of sleep. The patients RDI was only 9 events per hour of sleep. Therefore, the UPPP was not clinically indicated for this patients mild sleep apnea. Conservative therapy would have been more appropriate given these clinical findings.