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

A 55-year-old female enrollee has requested Euflexxa injections for treatment of her osteoarthritis of the knees.  Findings:  The physician reviewer found that lussier and colleagues report that Hyaluronan viscosupplementation therapy has been an accepted treatment for the treatment of osteoarthritis of the knee for many years. However, Dagenais noted that the efficacy is greater in patients with mild to moderate degeneration, while Wang found the therapy even less effective in patients with advanced disease. Although there have been some reports of benefits from repeated series of injections (Waddell, et al.), there have been reports of increased frequency of problems including local reactions (Leopold, et al.). As such, Cole and Malek reported that there remains a need for controlled, blinded, prospective studies to evaluate the benefits and risks of repeated injections. In the absence of data demonstrating the positive health outcomes in this patient subset, there is inadequate evidence to establish the medical necessity of repeated courses of viscosupplementation for management of this patients osteoarthritis. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for hyperbaric chamber treatments. There is a paucity of peer-reviewed medical literature consisting of medical studies or trials demonstrating the benefit of hyperbaric oxygen therapy in patients with a diagnosis of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). Studies on hyperbaric oxygen therapy in patients with PANDAS or other neuropsychiatric syndromes have not demonstrated improved health outcomes. Swedo and colleagues noted that the therapeutic interventions are limited to symptomatic treatments, including medications and behavioral therapies. The authors found that selective serotonin reuptake inhibitors (SSRIs) have been shown to be beneficial for patients with PANDAS. All told, the requested hyperbaric chamber treatments 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 internal medicine with subspecialty certification in pediatric allergy and  immunology 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 25-year-old male enrollee requested substance abuse residential for treatment of his alcohol, marijuana and cocaine dependence.  Findings:  A 25-year-old male enrollee requested substance abuse residential for treatment of his alcohol, marijuana and cocaine dependence.  Findings:  The physician reviewer found that substance abuse residential rehabilitation was medically indicated for the treatment of this patient.  Based upon the medical records, the services provided were for active treatment and were reasonably expected to improve the patients condition while preventing a more serious episode of illness.  Further, the duration of treatment was consistent with community treatment standards.  All told, substance abuse residential rehabilitation was medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Jakafi for treatment of the enrollees graft versus host disease (GVHD).Findings:  Two physician reviewers found that GVHD commonly affects organs including the skin, gastrointestinal tract, and liver. First-line treatment of GVHD is steroids. Second-line options include MMF, etanercept, photopheresis, mesenchymal stromal cells, sirolimus, and pentostatin. Other drugs that can be considered include monoclonal antibodies directed against CD25, TNF-alpha, T-cell receptor, and the IL2 receptor. Jakafi has been studied and results demonstrate efficacy in GVHD. A multicenter retrospective study demonstrated an associated 81.5% response, including 25 complete responses.  Final Result: Two reviewers determined that the requested medication is 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: All three physician reviewers are is board certified in internal medicine with sub-specialty certification in medical oncology 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

The spouse of a 71-year-old male enrollee has requested reimbursement for skilled nursing facility services for treatment of the enrollees paraplegia and Parkinsons disease. Findings:  The physician reviewer found that the patient did not receive daily skilled rehabilitation services, as his neurologic status did not warrant these services, and he also had progressive paralysis and pain. He had no daily injections. The patients pressure ulcers were stage II and did not require wound care at a skilled nursing level. The patient did not receive daily skilled services.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 20-year-old female who states that she has been ill since age 12 with symptoms that include low grade fevers, headaches, lightheadedness, dizziness, night sweats, sore throat, swollen glands, stiff neck, right-sided weakness (knees, hip) heart palpitations, nausea, poor sleep, poor concentration and memory loss, back pain and jaw pain.  From the records provided by her treating physician it appears she received IV Rocephin from July 2005 through October 2005.  In late August 2005 the record indicates that her percutaneously inserted central catheter (PICC) was removed due to an intravenous line infection.   Records from mid September 2005 note her drug therapy regimen and remark that she had diarrhea while on Augmentin. Notes from late September indicate that she had headaches, that her fever had declined and that she had a pituitary microadenoma.  When the patient was seen in October 2005, a positive Lyme serology and treatment with Rocephin were documented. Laboratory tests provided for review included abnormal liver function tests [AST, ALT] and an elevated serum potassium (5.9 mEq/L) on 9/27/05.  In November 2004 the Lyme IgG Western Blot is negative and the IgM is positive. The patient requested continued authorization and coverage for IV Rocephin, which was denied by the Health Plan based upon a determination that the IV antibiotics were not medically necessary.The patient has already received at least three months of treatment with IV Rocephin. This greatly exceeds the recommended therapy for any form of Lyme disease. Additionally, the evidence provided does not support a diagnosis of Lyme disease. The Centers For Disease Control approach (screening test followed by Western Blot studies) remains the accepted route to a serological confirmation of Lyme disease.  In this case, there was a positive IgM Western Blot in the face of a negative IgG Western Blot. Given the lack of any clinical evidence of acute Lyme disease in prior months, this is most likely a false positive result, as the IgM is often falsely positive.In this case, the diagnosis of Lyme disease has not been substantiated.  Even if there was good evidence of Lyme disease, there is no support for treatment with IV antibiotics for a period of over 30 days. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-year-old male enrollee requested authorization and coverage of the medication Nutropin. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees short stature.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old female enrollee has requested general anesthesia provided during a colonoscopy for evaluation of her extensive pelvic adhesive disease. Findings:  The physician reviewer found that this patient had risk factors and medical conditions which included a history of pelvic adhesions secondary to endometriosis, and a history of invasive rectal trauma which required the use of deep sedation during the procedure. The documentation indicates the medical necessity for the anesthesia care provided during the colonoscopy. All told, general anesthesia provided during the colonoscopy was medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

 A 27-year-old male has requested Cymbalta 60mg, two capsules per day for treatment of his joint pain.  Findings:  The physician reviewer found that Cymbalta (Duloxetine) is medically necessary treatment for the patients medical condition. The patient has tried and failed to benefit from standard therapy. Additionally, the patients medical condition is both chronic and seriously debilitating. Cymbalta is supported in the peerreview medical literature as a safe and effective treatment for combined disorders of chronic joint pain and depression.A study by Citrome, et al. examined the use of Duloxetine for the treatment of osteoarthritic pain. The authors reported that Duloxetine received FDA approval in 2010 for the indication of chronic musculoskeletal pain, including osteoarthritis. The authors concluded that the new data supports the application of Duloxetine for the treatment of chronic musculoskeletal pain. Skljareviski and colleagues performed a randomized double blind placebo controlled study to assess the efficacy and safety of Duloxetine in patients with chronic low back pain. The authors found that Duloxetine treated patients reported greater reduction in pain than  the placebo-controlled group and concluded that the data demonstrates the efficacy and safety of Duloxetine in the treatment of chronic low back pain. The authors also reported that Duloxetine received approval for treatment of chronic low back pain in 2010. In sum, the requested medication is medically necessary to treat the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 35-year-old female who was diagnosed with rheumatoid arthritis in February 2005 with a rheumatoid factor markedly elevated at 441. She tried several medications including Enbrel, Remicade and then Humira. Humira combined with methotrexate and prednisone at 40mg every other week did not control her rheumatoid arthritis but Humira once a week along with the other medications did stabilize the patients condition. The medical records document active disease at the time of diagnosis with an ESR of 109. On Humira once per week, the patients ESR decreased to 20 and her CRP was 1.68 (March 2006). When the frequency of Humira decreased to every other week, the patients CRP rose to 3.33 and her ESR rose to 42 (June 2006).  A September 2005 MRI demonstrated erosion of the metacarpal joints and the patients provider noted active synovitis on physical examination in June 2006.  The patient was treated with weekly Humira until April 2006 when there was a change in her Health Plan.  Her rheumatologist noted that the patients rheumatoid arthritis did improve with Humira at 40mg once per week.  The patient has requested authorization for Humira injections at a frequency of once per week.  The Heath Plan denied the request based on a determination that the requested dosage/frequency is not medically necessary.The patient has very active and aggressive rheumatoid arthritis. There are markers of poor prognosis with elevated rheumatoid factor and erosive changes on MRI. The patient showed improvement with Humira once per week, but not at an interval of once every two weeks. Continued treatment at the requested frequency of once per week has the potential to mitigate the patients symptoms and to prevent further joint damage. It is the standard of care within the rheumatology community to prescribe for maximum benefit to the patient. 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: Experimental/Investigational
Decision: Overturned

A 53-year-old female enrollee has requested Abraxane therapy for treatment of ovarian cancer.  Findings:  Two physician reviewers found that Abraxane is a protein-bound form of Taxol and has been found to be at least as effective as Taxol in the treatment of breast cancer, without the property for acute toxic reactions. Though it is expected that Abraxane will eventually be useful as a substitute for Taxol in a variety of cancer types, there is as yet, no real data that Abraxane can be successfully used instead of Taxol in ovarian cancer. However, the use of a taxane (whether it be Taxol or Taxotere) is an important component in the treatment of ovarian cancer. This patient has experienced acute and severe allergic reactions to both Taxol and Taxotere, precluding their further use. Abraxane is a reasonable and medically indicated substitute taxane without the known risk of an acute toxic reaction.
Appeal type: Medical Necessity
Decision: Overturned

A 34-year-old female has requested intravenous immunoglobulin (IVIG) home therapy for treatment of multiple sclerosis.  Findings:  The physician reviewer found that the patient has a history of multiple sclerosis with recent exacerbation and is breast feeding. She has been on platform medications in the past. Treatment with interferon is not advisable during breastfeeding, per the prescribing information. It is not known if Copaxone is excreted in breast milk. It is also not known if IVIG is excreted in breast milk. However, a recent review of seven randomized trials evaluating IVIG for relapsing-remitting MS supports the use of IVIG and a consensus statement indicated, For women with relapsing-remitting MS who are pregnant or breastfeeding, the panel agreed it is reasonable to consider IVIG as a treatment option. (Feasby, et al.) Therefore, there is indication of need for treatment in this patients case, and IVIG represents a medically reasonable treatment option until the patients platform medications such as Rebif and Avonex can be resumed.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a right ear hearing aid. There is a lack of consensus on the criteria for hearing aid candidature and variability in the use of hearing aids in clinical practice among patients with mild hearing loss. In a study to assess the long-term effectiveness of interventions to promote the use of hearing aids, Barker and colleagues found that There was no evidence of a statistically or clinically significant effect on hearing handicap, hearing aid benefit or the use of verbal communication strategies in the short to medium term. In this case, the patient has normal hearing in her right ear, with a speech reception threshold of 10 dB, indicating that she can hear 50% of the words at a 10 dB level, which is quieter than a whisper, and 100% word discrimination at conversational speech levels. Therefore, a right hearing aid is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested device 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 otolaryngology 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 61-year-old male enrollee has requested for Synvisc therapy for treatment of his osteoarthritis of the ankle.   Findings:  Three physician reviewers found that Synvisc injections have been approved for use in the knee, but there has been no documented approval for the use of Synvisc in the shoulder, elbow, hip, or ankle.  There is no documentation that viscosupplementation, such as Synvisc, is appropriate for post-traumatic arthritis of the ankle.  Although this patient has had treatment in the past, and it has been deemed to be helpful, it would not be medically appropriate to approve the viscosupplementation with Synvisc due to the fact that it has not been proven to be appropriate care for ankle arthritis.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested  for speech therapy for treatment of the enrollee, who has Down syndrome. Findings:  The physician reviewer found that the current medical evidence supports the requested speech therapy in this clinical situation. Many children with Down syndrome have cognitive deficits, as well as difficulty with speech.  Speech intelligibility, in particular, is a significant and prominent problem.  As noted by Kumin, the factors that affect speech intelligibility for children with Down syndrome include difficulty with combining, organizing, and sequencing the movements necessary for speech. It is essential to facilitate development of communication skills in children with global disabilities, particularly when intelligibility is compromised, so that they can express their needs in a functional way.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for microvascular decompression (MVD). Findings:  The physician reviewer found that the request for MVD is medically necessary for treatment of the patients medical condition. There is sufficient medical literature supporting the requested surgery in this clinical setting. MVD surgery for trigeminal neuralgia provides a low-risk treatment for cranial nerve hyperactivity-compression syndromes, which are associated with severe, disabling facial pain and spasm. In addition, studies note that MVD is likely the most effective therapy for patients with trigeminal neuralgia. In this case, the patient presents with medically refractory trigeminal neuralgia with persistent pain. As such, the requested surgery has been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested surgery 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 neurological 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested emergency services on an emergent basis or urgent basis. Findings:  The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with a headache. She also had been experiencing sinus congestion, rhinorrhea, sore throat and earache. She did not report any symptoms of confusion, or disorientation. The patient was mildly tachycardic, but was afebrile. She was described as in no acute distress. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe she was suffering from a serious medical condition. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services at question did not meet prudent layperson criteria for emergency care.  Further, it has not been established that criteria for urgently needed services were met on the date in dispute. In this case, the patient presented with headache, sinus congestion, rhinorrhea, sore throat and earache. She did not report any symptoms of confusion, disorientation, or fever. She was described as in no acute distress. The patient did not require any intravenous medication. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe she was suffering from a serious medical condition. The patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. In sum, based on the patients clinical presentation on the date in question the patient did not meet prudent layperson criteria for urgently needed services. As such, the Health Plans denial should be upheld.  Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in emergency 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: Medical Necessity
Decision: Upheld

The representative of a 47-year-old male enrollee has requested skilled nursing care services for treatment of the enrollees medical condition status post intracerebral hemorrhage.  Findings:  The physician reviewer found that this patient has experienced a devastating stroke of high severity. It is expected he will remain dependent. However, he has experienced a hemorrhagic stroke. Outcome for hemorrhagic stroke in a patient under 50 years of age is highly varied. Predicting outcome after a hemorrhagic stroke in this patient population is not a highly reliable exercise because progress in therapy may not be as limited as it is under other circumstances and because the degree and rate of brain healing is highly varied. This patient has experienced a stroke of high severity with the expectation that he will remain dependent on his caregivers. The occupational, physical and speech therapy records provided for review demonstrate that he has only made minimal progress, has a severely reduced capacity to respond to therapy, and has achieved a functional plateau. All told, the patient is unable to progress with daily skilled therapy due to the severity of the brain injury and the expected rate of brain healing. Therefore, the services at issue have not been established as medically necessary in this patients care.