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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a power wheelchair for treatment of her lower back pain and foot numbness and weakness.  Findings:  The physician reviewer found that there are no medical indications in the submitted records to establish the patient would be bed confined without a power mobility device. Per the patients documentation, there is no significant pertinent neurological or musculoskeletal impairments that would preclude ambulation with a cane or walker. There is also no evidence that the patient cannot walk without an assistive device. While the patient has poorly sized crutches, these issues can be addressed with new or adjusted crutches or a walker that is better suited for her physical frame. This could be followed with gait training, as recommended by physical therapy. There are also no significant pertinent neurological or musculoskeletal impairments that would preclude self-propulsion of an appropriately fitted manual wheelchair. Medical studies support the use of higher levels of physical activity rather than the lower levels of physical activity that a power mobility device would encourage (Hagen et al and Keyser et al). All told, the requested power wheelchair is not medically necessary in treatment of this patients medical condition.   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.  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: Experimental/Investigational
Decision: Overturned

The parent of a 16-year-old male enrollee has requested Erwinia L-asparaginase for the treatment of his acute lymphocytic leukemia (ALL). Findings:  Three physician reviewers found that Asparaginase therapy is a very important part of ALL therapy, particularly T-cell ALL. In the presence of a hypersensitivity reaction to PEG-asparaginase, the only alternative is Erwinia L-asparaginase. This is not yet FDA-approved. The International Acute Lymphoblastic Leukemia Working Group study in 2006 supports this use. The standard of care in pediatric oncology is to use Erwinia L-asparaginase in this situation. Pediatric oncologists do not consider this experimental, although not yet FDA approved.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female enrollee has requested for continuing outpatient mental health treatment with an out-of-network provider for treatment of her generalized anxiety, depression and posttraumatic stress disorder. Findings:  The physician reviewer found that this length of additional therapy is medically necessary to prepare the patient for a safe transition to an in-network provider.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret 100-40 mg. The submitted documentation supports the medical necessity of the requested medication regimen. 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 should be treated, except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret 100-40 mg. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. For these reasons, Mavyret 100-40 mg is medically necessary for this patient.Final Result: The reviewer determined that the requested medication regimen 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 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: Upheld

The patient is a 59-year-old edentulous male with a history of hepatitis C. He reports that he has difficulty eating. His present weight is 140 pounds. The patient is 67.75 inches tall, resulting in a body mass index of 21.6. The submitted materials indicate he has lost 10 pounds within the past year. The patients provider has prescribed Boost Plus nutritional supplement. At issue in this case is whether the requested supplement is medically necessary for the patient. Review of the submitted clinical records reveals no evidence of malnutrition. There is no documented history of odynophagia. The patient has no pathology involving his swallowing mechanism. Furthermore, based on his body mass index he is currently at ideal body weight. Moreover, there is no documentation indicating the patient cannot tolerate pureed, juiced or blenderized food. Therefore, I have determined the requested supplement is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz XR 11 mg. Findings:  The physician reviewer found that this patient has been diagnosed with rheumatoid arthritis, but also has sicca syndrome and Raynauds disease. It is not clear that the patient does not actually have undifferentiated or mixed connective tissue disease, for which Xeljanz is not U.S. Food and Drug Administration (FDA) approved. The patient may not be able to tolerate nonsteroidal anti-inflammatory drugs or methotrexate, but the records do not document why the patient cannot be treated with multiple other non-biologic disease-modifying antirheumatic drugs or anti-tumor necrosis factor drugs, including Plaquenil, Arava, Imuran, sulfasalazine, CellCept, Enbrel or Humira. Disease-modifying antirheumatic drugs are considered first-line agents for the treatment of rheumatoid arthritis. After the failure of disease-modifying antirheumatic drugs, anti-tumor necrosis factor drugs are preferred prior to Xeljanz. The requested therapy with Xeljanz is not superior to the formulary plan preferred drugs in terms of efficacy or safety. Therefore, Xeljanz XR 11 mg is not medically necessary for the 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 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: Upheld

The patient is a seven-year-old female with a history of expressive/receptive language delays and abnormal auditory processing. In March, 2006, her pediatrician documented additional symptoms, which may place the patient on the autism spectrum. The pediatrician has recommended, further psycho-educational testing to delineate the patients developmental disabilities.  The patient has been receiving speech therapy since September 2005. The submitted speech therapy evaluations indicate the patient has met 5 of 7 goals and has made progress toward the other goals. At issue is whether speech therapy is medically necessary for treatment of the patients condition.The patients diagnoses of expressive/receptive language disorder and abnormal auditory processing disorder have not been documented to have a medical basis and are generally considered educational in nature. In such cases, speech therapy is not medically warranted and is usually provided through the school system. However, the submitted evidence indicates neuropsychological testing has been recommended by the patients provider to help delineate the patients developmental disabilities. Speech therapy is considered standard of care in autistic children. If neuropsychological testing results in a diagnosis of an autism spectrum disorder such as pervasive developmental disorder  not otherwise specified, speech therapy would be considered medically appropriate and medically necessary in light of the gains the patient has been making in therapy to date.  Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. If neuropsychological testing reveals a diagnosis of an autism spectrum disorder, speech therapy should be authorized. If neuropsychological testing does not reveal a diagnosis of an autism spectrum disorder, speech therapy should not be authorized.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the laboratory testing (CPT 83520) provided by Athena Diagnostics, Inc. Findings:  The physician reviewer found that evaluating data on the current status of biomarkers for Alzheimers disease, Blennow and colleagues report that while a large number of clinical studies very consistently show that these biomarkers contribute with diagnostically relevant information, also in the early disease stages,  future studies are warranted to validate these promising results further. In this case, the patient presented with complaints related to memory deficits. While the use of biomarker testing may be helpful, their results have not been demonstrated to be diagnostic, as diagnosis of cognitive disorders remain based on clinical evaluations including a patients history and neuropsychological studies. Therefore, the laboratory testing provided by Athena Diagnostics, Inc. was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the laboratory testing  provided by Athena Diagnostics, Inc. at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in neurology and are actively practicing. Physician reviewer 2 is board certified in board certified in neurology with sub-specialty certification in vascular neurology 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: Urgent Care
Decision: Overturned

A 21-year-old male has requested reimbursement for lab testing provided while staying at a recovery center. Findings:  The physician reviewer found that the patient was hospitalized for hypothermia and bradycardia related to malnutrition and secondary to alcohol abuse.  He was treated for approximately two days but then left the hospital against medical advice (AMA), flew to Florida (where his parents live), and checked into a recovery center.  His vital signs were grossly abnormal with a heart rate of 44, respiratory rate of 10, and temperature of 95.2F. His blood pressure was low normal at 96/64.  He was treated for five days for malnutrition related to his alcoholism, many laboratory tests were performed, and he was discharged. The patient was released from the recovery center because the providers at the facility felt he required a higher level of care. At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention during the time frame under review. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.This patient was critically ill at the time of his admittance to the recovery center.  He needed emergency care and he needed to be hospitalized for that care.  Despite the fact that the patient left the hospital and sought treatment at a non-acute care facility, he did have grossly abnormal vital signs, and a prudent layperson would have thought this to be an emergency medical condition and would have sought immediate medical attention.  The patients symptoms during the time frame under review met prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would reasonably expect the absence of emergency care to jeopardize their health.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Forteo for treatment of the enrollees osteoporosis.Findings:  The physician reviewer found that in review of the submitted documentation and relevant literature demonstrate the medical necessity of the requested medication. According to the National Osteoporosis Foundation guidelines for severe osteoporosis, sequential treatment with anabolic therapy followed by an antiresorptive agent is generally preferred to concomitant combination therapy. Forteo is an anabolic agent approved by the U.S. Food and Drug Administration (FDA) for the treatment of osteoporosis in postmenopausal women and men at high risk for fracture. Forteo reduces the risk of vertebral fractures by about 65% and nonvertebral fragility fractures by about 53% in patients with osteoporosis, after an average of 18 months of therapy. Prolia is an antiresorptive agent that decreases the risk of spinal fractures by 68% and hip fractures by 40% and is indicated for the treatment of osteoporosis in men and women at high risk for fracture. Early studies have shown that the use of antiresorptive agent prior to or concomitant to Forteo blunt the beneficial effects of Forteo. It has been demonstrated that sequential monotherapy of Forteo followed by an antiresorptive agent is more effective than monotherapy with an antiresorptive agent alone. It has been shown that the greater effect of Forteo occurs after one year of therapy, and the benefit is maintained when followed by an antiresorptive agent. Moreover, when a patient presents with severe bone loss and compression fractures, Forteo for one or two years followed by an antiresorptive agent is recommended. The reverse order may have blunted results, and it is not as effective. Final Result: The reviewers 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 physician 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 is a 52-year-old male who has a history of migraine headaches. He experiences two headaches per week, eight per month. He has been prescribed triptans (i.e., Imitrex nasal spray and Zomig) as abortives. He was previously seen by a neurologist. He reportedly has used Inderal and Pendil in the past as preventives without success. The patient is currently using Norvasc as a preventive for headache. No headache diary information is supplied. No information is given to indicate that headache frequency, severity or duration have been altered by this medication. Imitrex nasal spray gives the patient rapid relief and if he has headache recurrence the next day he uses Zomig. The patient has requested authorization for 12 sprays of Imitrex 20mg per month. The patient has reportedly had benefit with abortive use of a triptan, Imitrex NS for migraine. The patient experiences eight headache days a month at present and some of those may be due to recurrence or several headaches grouped together in a row. At this headache frequency, preventive medications are indicated. The patient has tried Inderal at an unstated dose and duration. It is therefore not known if the patient failed Inderal or was taking an inadequate dose. He has tried a calcium channel blocker, Norvasc, without significant improvement in headache pattern. In general, calcium channel blockers do not have good evidence of benefit as migraine preventives. Several agents including propranolol, timolol, amitriptyline, divalproex and topiramate have evidence as successful first-line agents for migraine prevention. Identification of an effective preventive may take several weeks or months on treatment. It is acceptable per package instructions to re-treat with a second dose of Imitrex nasal spray or Zomig two hours after a first dose, but no more than two doses in a 24-hour period. Thus, the use of 16 doses of a triptan in a month is within the package instructions. However, this does not constitute optimal treatment and should only be continued until the patient can be re-evaluated by a neurologist for development of a treatment plan including the use of preventives such as timolol, amitriptyline, divalproex or topiramate. Consequently, I have determined the patients request for 12 sprays of Imitrex 20mg per month is medically necessary for a period of three months from the date of this decision to allow the patient adequate time to start a new regimen that includes the use of preventives. Accordingly, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for fertility preservation services (stimulation and removal of her oocytes, inseminating the oocytes, and the cryopreservation of the embryo). Researchers found that fertility preservation in both female and male oncological patients is now possible and should be integrated as part of the oncological healthcare. In this case, the patient had negative margins from the initial excisional procedure. According to medical literature, the rates of residual AIS, recurrent AIS, and concomitant or subsequent invasive adenocarcinoma in this clinical setting are approximately 2.6%, 20%, and less than one percent, respectively. For this patient, a hysterectomy after completion of childbearing is recommended, although continued surveillance is a reasonable option if the patient has consistently normal testing, particularly for five or more years, following their cone biopsy. The records do not note that the patient is undergoing any cancer therapy or gonadotoxic treatment such as radiation therapy or chemotherapy. While the patient has a low risk of losing her uterus, they are not at risk of having their ovaries removed. Given the absence of gonadotoxic treatment or possible damage to the ovaries, the requested services are not medically indicated. Therefore, fertility preservation services (stimulation and removal of her oocytes, inseminating the oocytes, and the cryopreservation of the embryo) are not medically necessary for the 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 obstetrics and gynecology with sub-specialty certification in reproductive endocrinology and infertility 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 61-year-old female enrollee has requested Lyrica for treatment of her fibromyalgia.  Findings:  The physician reviewer found that Lyrica is medically indicated for the patients medical condition of fibromyalgia. Lyrica is FDA approved for fibromyalgia. Mease and colleagues evaluated the efficacy and safety of pregabalin (Lyrica) for symptomatic relief of pain associated with fibromyalgia and for management of fibromyalgia in a multicenter, randomized, double-blind, placebo-controlled trial. They found that patients in all pregabalin groups showed statistically significant improvement over the placebo group. Shneker and McAuley reported that Lyrica was a highly effective medication for a wide variety of conditions including seizure disorder, peripheral neuropathy and fibromyalgia.  All told, the peer-reviewed literature supports the safety and efficacy of Lyrica for the treatment of fibromyalgia. In this patients case, Lyrica is medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

A 46-year-old male enrollee requested authorization and coverage of intradiscal electrothermal therapy (IDET). The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees back pain.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested procedure is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.