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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Praluent.  Findings:  The physician reviewer found that based on the records provided, the patient presents with hyperlipidemia.  She is intolerant of two statin medications, and there is no documentation of obstructive coronary disease.  Per the records, her calcium score is only mildly elevated and does not equate to obstructive coronary disease.  Moreover, the documentation does not support the patient has familial homozygous or heterozygous hyperlipidemia.  These diagnoses require not only elevated low-density lipoprotein levels that significantly exceed 180 mg/dL, but also a combination of physical examination findings (arcus cornealis below the age of 45, tendon xanthomata), a strong family history of coronary disease (younger than 50 years in second-degree relative or aged younger than 55 to 60 years in first-degree relatives) and documented genetic defects related to cholesterol metabolism according to published criteria.  Praluent is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of low-density lipoprotein levels. This patient does not fit these criteria.  PCSK9 inhibitors have not been studied in other patient populations, such as this patient.  Current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting.  Finally, there are other statin medications, such as fluvastatin, which have lower side effect profiles and have not been documented to be tried or not tolerated in this patient. Therefore, Praluent is not medically indicated 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 physician reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 parent of a 17-year-old male enrollee requested treatment center (RTC) services for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the patient had been in almost continuous treatment for substance abuse and it is unclear what further benefit he would derive from another residential admission. His substance abuse disorder does not appear to be amenable to active behavioral health treatment. Psychiatrically he appeared to be stable. In addition, based on his treatment history and staff description during process groups, it appears that he was not ready to work on the development of coping skills or behavioral changes. He was not a danger to himself or others. In addition, his home environment would not undermine his rehabilitation at a lower level of care as his mother is supportive.  In sum, the patient could have been appropriately treated at a lower level of care in which he could develop the motivation to understand his substance abuse issues, and develop coping mechanisms and plans for the future.  Based on the medical literature cited above and the documentation submitted for review, the services were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old female enrollee has requested magnetic resonance imaging (MRI) of the cervical spine and shoulder for evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services.  This patient has left upper extremity symptoms which have persisted despite surgery involving both the wrist and left shoulder.  Her pain and tingling may be due to cervical impingement.  Since this patient has already had two procedures on her left upper extremity without relief, there is sufficient support for the requested MRI of the cervical spine to evaluate the cervical spine as a possible cause of the patients symptoms.  However, the medical necessity of the requested shoulder MRI has not been established.  The most recent physical examination does not address the left shoulder, and there is a lack of documentation regarding conservative therapy concerning the right shoulder.  Per the current medical evidence, there is no medical indication to proceed with MRI of the right shoulder prior to conservative management.  All told, a portion of the requested services (MRI of the cervical spine) is medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee has requested speech therapy at a frequency of two 30-minute sessions per week for treatment of the enrollees speech delay and pervasive developmental disorder - not otherwise specified.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates that speech therapy is medically necessary for this patient with autism spectrum disorder (ASD) and history of expressive language delays with socialization, pragmatic, and articulation deficits. Language deficits are one of the core aspects of autism; speech therapy provides professional help and guidance on communication development for individuals with ASD (Volmar and Wiesner). Language skills make a significant difference in the ability of children to control their environment especially those children with social skills deficits (Goldstein). Goldstein reviewed communication interventions for autism in peer-review research articles published over the past 20 years. The evidence supported the claim that effective interventions such as speech therapy exist to teach communication skills to children with ASD. This patients most recent school evaluation notes delays of 25-30% in articulation skills. Based upon this evidence, the patient is an appropriate candidate for speech therapy. The requested speech therapy at a frequency of two 30-minute sessions per week is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested stereotactic radiotherapy (SRT) with Novalis for the treatment of her olfactory neuroblastoma. Findings:  The physician reviewer found that the form of radiation therapy that has been proposed is stereotactic radiosurgery with Novalis. Various techniques of radiation have been utilized in this setting including 3D-conformal radiation and IMRT (which the Health Plan has proposed as an alternative). For this patient, IMRT is the preferred technique as the tumor is very close to the optic nerves, optic chiasm, eye and brain. Daily localization and verification of radiation fields can be done with IMRT. With regard to whether stereotactic radiosurgery offers any additional benefit over IMRT in this setting, there are no randomized trials comparing stereotactic radiotherapy and IMRT for rare tumors like olfactory neuroblastoma. Based upon the evidence available to date, there is insufficient evidence that stereotactic radiosurgery is likely to result in a superior clinical outcome as compared to IMRT.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. This gives the patient a composite score which is consistent with high intensity community based services, such as IOP. Per CALOCUS, minimal oversight should be required for this level of services and reviews should not be required more often than every two weeks for persons with acute conditions and every two months for those with more slowly evolving conditions. The patient qualifies for up to two more months of IOP services. Accordingly, the mental health IOP services were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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 with subspecialty certification in 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested Harvoni for medical treatment of her hepatitis C virus.  Findings:  Two physician reviewers found that the U.S. Food and Drug Administration (FDA) has approved Harvoni for patients with early stage disease. Moreover, according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. In this case, the patient has chronic HCV and AASLD/IDSA guidelines support treating this patients HCV with Harvoni. Therefore, Harvoni is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested intravitreal Avastin eye injections for treatment of his medical condition.   Findings: Three physician reviewers found that the services at issue have been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is sufficient support for the services at issue in this clinical setting. According to the report on bevacizumab treatment for radiation retinopathy affecting the macula by Finger, Intravitreal bevacizumab can be used to treat radiation retinopathy. In most cases treatment was associated with decreased vascular leakage, stabilization, or improved vision. Thus, Avastin has been shown to be effective in restoring vision lost in patients who developed radiation maculopathy after radiation therapy. Given the support above, Avastin eye injections  were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: All three reviewers determined that the services at issue were 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 reviewers are board certified in ophthalmology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia services provided during a colonoscopy. According to the American Society of Anesthesiologists guidelines for anesthesia care during endoscopic procedures, monitored anesthesia care is warranted in prolonged or painful procedures, such as complex polyp resections, endoscopic retrograde cholangiopancreatography or other biliary procedures, endoscopic dilation, or endoscopic resection. Additionally, the guidelines state that monitored anesthesia care may be necessary in patients with failed history of moderate sedation for the procedure or psychological impediments to cooperation. The provided records do not support any of these criteria, or other criteria in the literature, such as difficult intubation, airway obstruction, allergies to sedation medications, chronic alcohol or illicit drug use resulting in increased tolerance to sedation medications, pregnancy, increased aspiration risk, ASA class III or higher, or morbid obesity. All told, anesthesia services provided during a colonoscopy were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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 53-year-old female with a history of a cyst on her right eye. The cyst has apparently recently grown in size. The patients provider has recommended excision of the cyst. The Health Plan has denied this request.The clinical evidence does not demonstrate the medical necessity of the requested medication. The submitted photographs do not provide clear or objective evidence of the patients condition. The drawing in the ophthalmologists record shows a moderate pinguecula with only a tiny extension onto the cornea. These are common, benign and virtually never require surgery. If they enlarge and extend onto the cornea, they are classified as pterygium. A decision to proceed with surgery would then be based on the extent to which the pterygium extended into the visual axis. There is no evidence of this in this case. Furthermore, inflamed pinguecula usually respond to topical therapy. There is no evidence this patient has attempted a trial of topical therapy. Moreover, a biopsy would be indicated prior to consideration of surgery after failure of topical therapy. Based upon the information set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for RT300 functional electrical stimulation (FES) therapy system. Findings:  The physician reviewer found that Reports from prospective randomized controlled clinical trials for the effectiveness of the RT300 FES cycling in patients with spinal cord injury (SCI) remains limited. There is insufficient evidence in the literature to support that the use of the RT300 FES will be effective for the treatment of patients with SCI. There is a paucity of data that the RT300 FES provides long-term improvement of muscle strength, vascular blood flow, bone mineral density, reduction of spasticity and atrophy, or facilitation of functional motor movement. Furthermore, with regard to circulatory function, a study by Barton and colleagues revealed that low-intensity FES increased blood flow during stimulation. However, there is a lack of evidence that these findings have a lasting effect on circulatory perfusion and reduce the risk of vascular complications. The  long-term health benefits of using  an RT300 FES  in the home is unclear as the evidence is insufficient to determine the effects of the technology on health outcomes. All told, the requested RT300 FES therapy system is not 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 RT300 FES therapy system is not 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 device is 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: Physician reviewer 1 is board certified in physical medicine and rehabilitation with subspecialty certification in neuromuscular medicine and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation 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: Experimental/Investigational
Decision: Overturned

A 59-year-old male enrollee has requested allogeneic bone marrow transplant for the treatment of his chronic lymphocytic leukemia. Findings:  Two physician reviewers found that this patient has high-risk chronic lymphocytic leukemia (CLL). He has poor prognosis molecular features (CD38 positivity) and high-risk clinical features including lymphocyte count greater than 200,000, rapid lymphocyte doubling time, and short response to initial therapy. Given these features, standard therapy is very unlikely to be effective. The patient has good performance status, has no serious co-morbidities, has poor risk disease and has not demonstrated drug resistance. As such, he meets current clinical criteria for allogeneic hematopoietic stem cell transplantation (allo-HSCT) in patients with CLL. This patient is an appropriate candidate for treatment with HSCT and is more likely to respond to the therapy than any standard alternatives.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Epclusa for 12 weeks for treatment of the enrollees hepatitis C virus.Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin. 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 parents of a 4-year-old male enrollee requested authorization and coverage of speech therapy for the treatment of asperger's syndrome.  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 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 patient has requested authorization and coverage for long-term acute rehabilitation services. Functional impairments due to acquired brain insults such as stroke can be profound. Some recovery is expected with time and many impairments are addressable by compensatory measures and directed rehabilitation efforts. Standard of care for this condition includes rehabilitation services, first in the inpatient setting if necessary, followed by rehabilitation in the community setting if still indicated, based on impairments and the potential for achieving practical, functional goals. Most of the significant neurological and functional recovery following a stroke occurs in the early stages after stroke and gains are slower to come in the subsequent stages (Alawieh, et al.; Kubis). Rehabilitation efforts are indicated at a level of intensity commensurate with deficits until care can be safely and effectively transitioned to a less intensive level of care. In the present case, the patient sustained multiple bilateral lacunar infarcts. There has been persistent encephalopathy, cognitive impairment, aphasia, dysphagia, and profound overall functional impairment. Based on the available documentation, she has not been able to meaningfully participate in therapies or make functional progress. There is a lack of verbal communication or demonstration of potential capacity to participate in intensive rehabilitation services. Thus, intensive rehabilitation services are not expected to be provide this patient with substantial benefit. Therefore, the requested long-term acute rehabilitation services 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.