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

A 40-year-old female enrollee has requested prescription medication Provigil for the treatment of spastic paraparesis.  Findings:  The physician reviewer found that many of the more standard therapies have been ineffective. Provigil is known to be safe and effective for other neurological conditions such as multiple sclerosis, and has resulted in functional improvement for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections. Researchers concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in a meta-analysis of 137 studies with 33,243 patients. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Researchers conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and reported that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. Researchers found that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis which failed conservative treatment was found efficacious during a 54-month follow-up period. In addition, current guidelines support hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. Guidelines stated that if there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to do another series. There is no maximum amount of injections established by high quality scientific evidence. This patient presents with severe recurrent right knee pain. Significant functional limitations are noted in walking tolerance and activities of daily living. Clinical examination findings have been consistent with reported right knee severe osteoarthritis. Reasonable conservative treatment, activity modification and corticosteroid injections, have failed to provide adequate symptom relief. He is unable to take NSAIDs due to acute and chronic renal failure. Records documented prior viscosupplementation had been performed on two occasions with six months of significant pain reduction and functional restoration. Evidence based medical peer-reviewed 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. Given these findings, the requested Orthovisc injections are supported as medically necessary for treatment of this patients medical condition. 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 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: Medical Necessity
Decision: Overturned

The parent of a 10-year-old male has requested applied behavior analysis (ABA) therapy for treatment of his autism.  Findings:  The physician reviewer found that the disputed ABA therapy services provided during the said timeframe ongoing are medically necessary for the treatment of this patients autistic disorder. At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and can be utilized to improve overall neurologic health. Thus, specific treatment, including therapy that may encompass a wide variety of modalities including ABA therapy, can be used to help induce brain plasticity. The ultimate goal of the therapy is to retrain neural circuitry not compromised by the underlying pathogenetic processes that give rise to autistic spectrum disorders and their co-morbidities including, but not limited to repetitive or stereotypic behaviors as well as deficits in communication, play skills, self-help skills, and sensorimotor repertoires essential to the activities of daily living. The evidence demonstrates that the skills relevant to age-appropriate activities of daily living improve with long-term application of ABA services during critical developmental periods in childhood. Therefore, the denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The enrollees parent is requesting reimbursement for the inpatient psychiatric treatment program level of care. The enrollee has unspecified psychosis and cannabis use disorder. She was admitted to the adolescent locked unit due to increasing anxiety, irritability and paranoid delusions.  She was hearing voices that were scaring her and demonstrated a preoccupation with religion. The family noted she had been sleeping poorly, was irritable, and had demonstrated self-neglect.  A progress note described the enrollee as easily overwhelmed and anxious. Medical records note she was still mumbling and talking to herself, and endorsing suicidal ideation; stating she would be better off dead.  She continued to feel she was being monitored and that people were out to harm her in some way. Medical records show the enrollee was not a threat to herself or others.  She did not require 24-hour nursing.  She was alert and oriented and had no medical problems.  Records noted it was unlikely that care provided only during the day would increase the enrollee's chance of relapse. The Child and Adolescent Level of Care Utilization System (CALOCUS), developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations and was used in this review. The enrollees composite CALOCUS score correlates with high intensity community-based services.Final Result: The reviewer determined that the requested service was not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and child and adolescent 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: Upheld

A 41-year-old female enrollee has requested Actiq for the treatment of her complex regional pain syndrome. Findings:  The physician reviewer found that Actiq is FDA approved for use in cancer patients. There are no randomized controlled trials of this medication in ambulatory non-malignant pain patients. Rather, there are several case series and individual case reports in the literature. Its effectiveness in non-malignant pain is unproven in randomized controlled trials. Bennett and colleagues describe several alternatives. Although this consensus document refers to Actiq, they refer to case series and case reports. Simon reports that published studies to date have focused on measuring analgesic effects in patients with cancer-related pain. He states that studies in chronic, non-cancer pain that also measure patient function are needed. Simon reports that unanswered questions include potential for an increased risk for opioid misuse and abuse, the potential for rebound pain and the potential for poorer patient compliance when analgesics are dosed as needed versus around the clock. Furthermore, there is a lack of studies involving the use of Actiq for this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee requested a 12-week course of Sovaldi 400 mg per day and ribavirin 600 mg for medical treatment of his hepatitis C virus (HCV).  Findings:  Two physician reviewers found that review of the submitted documentation fails to establish the medical necessity of the requested medications. According to the documentation submitted for review, the patient has minimal to no fibrosis despite years of infection with hepatitis C and chronic alcohol use. He has no systemic manifestations of hepatitis C such as cryoglobulinemia or leukocytoclastic vasculitis. Based on the clinical records submitted for review, national guidelines recommend monitoring his fibrosis levels non-invasively, 1-2 times annually and commence therapy if there is evidence of increasing fibrosis. Therefore, at this time the requested medication combination is not medically necessary for treatment of the patients HCV.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old male enrollee has requested coverage for selective internal radiation therapy (SIRT) radioembolization of metastatic liver tumors for treatment of his pancreatic adenocarcinoma with liver metastases.  Findings:  Two physician reviewers found that the patient has a past history of prostate cancer and was found to have multiple liver metastases several years ago. Biopsy demonstrated a signet ring adenocarcinoma with most likely a pancreatic primary. The patient was started on chemotherapy with Gemzar/Xeloda/Tarceva which was continued through three years when progression of disease was noted. He was then switched to Abraxane/Vandetanib and subsequently to FOLFOX with progression of disease. Most recently, the patient had re-staging of disease, with further evidence of progression. Pathology review found either stomach, pancreatic or biliary duct primary. The patient was not noted to be a candidate for a clinical trial but has been recommended for treatment with selective internal radiation therapy (SIRT) with Y-90 microspheres. Selective internal radiation therapy (SIRT) is the use of hepatic arterial embolization with microspheres loaded with radioactive Yttrium-90. The current data on the use of this therapy is limited. In 2008, Sato and colleagues reviewed their experience with SIRT in a wide variety of cancer types and concluded that although there appeared to be a significant response rate, in the absence of any controlled analysis it was not possible to determine the contribution of the treatment to patient outcomes. Townsend and colleagues concluded that of the available studies, phase III randomized, controlled trials were still needed to fully evaluate this modality. Thus, despite encouraging results from Kucuk and colleagues reporting that SIRT is a useful treatment in a number of patients with liver metastases, there is limited information as to tumor types and prior therapy. All told, this patient with presumed pancreatic primary disease and significant previous chemotherapy is not likely to experience an improved health outcome with SIRT.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a prolotherapy injection for treatment of the enrollees medical condition.  Findings:  Three physician reviewers found that there is limited peer-reviewed evidence that prolotherapy is more efficacious compared to standard therapy in treatment of hip pain. The literature provided in support of this appeal includes a case series and a pilot study, which are considered low-level evidence. The pilot study for a different tendinopathy states more research is needed to validate the claims of benefit. Thus, further studies are needed in order to support the use of prolotherapy in alleviating chronic hip pain. There is a lack of medical research showing that prolotherapy for hip tendinopathy has undergone the rigors of scientific research to move it from investigational research to standard of care. In this case, the patient had not yet exhausted all available standard therapy in treatment of her medical condition. Therefore, the requested prolotherapy injection is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:   All three reviewers are board certified in anesthesiology with sub-specialty certification in pain management 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for psychiatric emergency medical services. Findings:  The physician reviewer found that the medical services provided were necessary for treatment of a psychiatric emergency medical condition. Bipolar disorder is chronic and often disabling serious mental illness. Bipolar disorder is associated with poor clinical outcomes and a heightened rate of suicide. As such, potentially emergent physical symptoms in context of bipolarity should be addressed quickly and comprehensively. In this case, the patient presented with a non-specific but potentially concerning symptom complex. Further medical and psychiatric assessment to rule out life-threatening conditions such as suicidality, psychosis, stroke, myocardial infarction, infection and arrhythmia were emergent in nature. Thus, the services at issue were necessary for treatment of a psychiatric emergency medical condition. Final Result: The reviewer determined that the patient received psychiatric emergency medical services on the date of service at issue. 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: Medical Necessity
Decision: Upheld

The patient is a 45-year-old female with multiple medical problems who is requesting authorization for growth hormone therapy. The patient has a history of CVA in 1994; however, no evidence of pituitary injury has been submitted. In addition, no evidence demonstrates why the patient is on Armour thyroid. Furthermore, the patient has had two normal IGF-1 tests. The patient is on estrogen and progesterone because she is post-menopausal. The patients physician has recommended continued treatment with growth hormone therapy.There is no evidence this patient has adult growth hormone deficiency (AGHD) or hypopituitarism. Such a diagnosis is usually made based upon the clinical context that is suggestive of some disorder of the hypothalamic/pituitary axis. The patients IGF-1 appears normal and there is no other clinical evidence to support growth hormone therapy for this patient. Therefore, I have determined the requested medication is not medically necessary for this patient. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-year-old male with persistent pubertal gynecomastia is requesting reimbursement of a bilateral mastectomy.  Reviewers Findings:   The reviewing physician found that while the breast enlargement was not causing a physical functional impairment, the documentation submitted indicates that the breast enlargement was significantly affecting psychological functioning.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a six-year-old female enrollee requested authorization and coverage of speech therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees apraxia of speech.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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested direct 40 hours per week applied behavioral analysis (ABA) therapy and seven hours per week of supervision for treatment of the enrollees autism.  Findings: The physician reviewer found that the evidence for the effectiveness of early intensive behavioral intervention (EIBI) in increasing the functional behaviors and skills of children with autism. The authors reported improvements in cognitive skills, adaptive skills and communication. In this case, the documentation supports that ABA has been effective for this patient. However he continues to have maladaptive behaviors that include mouthing/licking, placing hands on others and grabbing behaviors. In addition, the patient has had an increase in maladaptive behaviors due to a decrease in ABA services. Therefore, a reduction of services is not indicated for this patient. Accordingly, the request for 40 hours per week of direct ABA therapy and seven hours per week of supervision are medically necessary for treatment of the patients medical condition.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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 Harvoni for treatment of her hepatitis C virus. Findings: The physician reviewer found that 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 non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for 8 weeks. These guideline recommendations are based on multiple randomized clinical trials. For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection.  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 physician 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Mavyret 40mg-100mg, three times daily, for eight weeks. The submitted documentation supports the medical necessity of the requested medication. 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 2 patients should be treated with Mavyret for 8 weeks. These recommendations apply regardless of fibrosis stage. The SURVEYOR-II trial showed a 99% cure rate with 8 weeks of treatment. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret 40mg-100 mg, three tablets daily, for eight weeks is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in gastroenterology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested a magnetic resonance imaging (MRI) for evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted records fail to demonstrate the medical necessity of the services at issue. Prior to an MRI of the shoulder, a six week trial of conservative treatment is necessary.  Moreover, there is no documentation or notes by the orthopedic surgeon addressing the progress of physical therapy. There is a lack of support for the services at issue in this clinical setting.  The physical therapy had not concluded prior to the MRI of the right shoulder. For these reasons, the MRI was not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.