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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for diclofenac sodium 3%. In the medical literature, a study assessed the benefits of various topical anti-inflammatory medications. The authors concluded that topical non-steroidal anti-inflammatory drugs (NSAIDs) provide good levels of pain relief in acute conditions such as sprains, strains and overuse injuries, probably similar to that provided by oral NSAIDs. Specifically, the authors noted that, certain formulations, mainly gel formulations of diclofenac, ibuprofen, and ketoprofen, provide the best results. In addition, researchers reported that, There is good evidence that some formulations of topical diclofenac and ketoprofen are useful in acute pain conditions such as sprains or strains. In this case, the patient has chronic knee pain with a recent episode of falling on his right knee after it buckled. The records document that he has been treated with steroid injections in the past with good effect and ibuprofen 600 mg to manage his knee pain. The patients provider has also recommended topical diclofenac gel 3% to apply to the knee given his acute on chronic episode of pain. Given this support, the requested diclofenac sodium 3% is medically necessary for treatment of this patient.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 anesthesiology with subspecialty certification in pain management 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 60-year-old male enrollee requested authorization and coverage of continued physical therapy by a therapist and a skin graft for the treatment of a below the knee amputation. 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 overturned the health plans denial on the basis that the requested therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The parent of an enrollee has requested authorization and coverage for a cranial (head) remolding orthosis custom helmet.Dolichocephaly is an elongation of an infants head that is frequently seen in premature infants due to post-natal positioning. This head molding/shaping is not unusual with breech presentations. Plagiocephaly is a flattening of the back of the head that is typically associated with supine positioning and sleeping. The first line of defense with these abnormal head shapes involves repositioning, and in the presence of torticollis, physical therapy. Significant abnormalities, with either one dominant abnormal head shape (e.g., positional plagiocephaly with diagonal difference > 10mm, brachycephaly > 91%, dolichocephaly < 82%) or a combination of abnormal head shapes (e.g., plagiocephaly with brachycephaly, plagiocephaly with dolichocephaly) merit use of a cranial orthoses to prevent unnecessary stress to the developing nervous system with subsequent neurologic issues. Tamber and colleagues conducted a study that concluded there is a fairly substantive body of nonrandomized evidence that demonstrates more significant and faster improvement of cranial shape in infants with positional plagiocephaly treated with a helmet in comparison with conservative therapy. In this case, the patient has moderate plagiocephaly and severe dolichocephaly based on anthropometric measurements. Under these circumstances, use of a cranial orthosis is medically necessary and appropriate to improve head shape and prevent unnecessary morbidity. Accordingly, the requested cranial (head) remolding orthosis custom helmet is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested equipment is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Sirturo (bedaquiline fumarate 100 mg tablet), dosed at 400 mg daily for 14 days, then 200 mg daily for three months total therapy. Findings:  The physician reviewer found that  the available medical records, the provider has followed an appropriate plan of treatment with use of progressively more aggressive therapeutics for management of this patients Mycobacterium abscessus (M. abscessus). The provider initially used standard oral medications and transitioned when near pan-resistance was noted. He then escalated to prolonged courses of intravenous (IV) amikacin, and tigecycline, in addition to IV imipenem. Despite these measures, the patient has failed to completely respond, and she required a return to surgery earlier in 2020 to resect out the affected area. The next logical step is to consider novel therapies that have demonstrated in-vitro activity against atypical mycobacterial species. Per the U.S. Food and Drug Administration (FDA) approval for Sirturo, it is used to treat multi-drug-resistant tuberculosis, and the nature of mycobacterial isolates has similar in-vitro susceptibility. Brown-Elliott and Wallace demonstrated that Sirturo may have potential use in the treatment of disease caused by M. abscessus complex. The medical literature supports the efficacy of Sirturo in resistant mycobacterial pathogens. Thus, the requested Sirturo (bedaquiline fumarate 100 mg tablet), dosed at 400 mg daily for 14 days, then 200 mg daily for three months total therapy, is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested Sirturo (bedaquiline fumarate 100 mg tablet), dosed at 400 mg daily for 14 days, then 200 mg daily for three months total therapy, is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested 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: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in infectious disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a podiatry referral. Per the reviewer, it is well documented in the progress notes that this patient suffers with bilateral foot pain that is unresponsive to cortisone injections, NSAIDS, orthopedic footwear and Icy Hot gel. The patient is unable to ambulate comfortably. An x-ray confirmed plantar calcaneal spur along with bilateral osteoarthritis of the foot. The patients primary care providers have been unable to treat this patients foot conditions. A podiatrist may have different insight into the patients foot pain which would allow for further treatment. Therefore, the requested podiatry referral is medically necessary.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is a board-certified podiatrist and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 37-year-old female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested injections are considered experimental for treatment of the enrollees hemifacial spasm.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Overturned

A sixty-eight year-old female with fecal incontinence is requesting reimbursement for a SECCA radiofrequency procedure.  Reviewers Findings:  The reviewing physician found that the SECCA radiofrequency procedure has been shown to be beneficial for patients such as this one and the literature supports the use of this modality in the treatment of fecal incontinence.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female enrollee has requested for a Phase I clinical trial of Avastin and valproic acid for treatment her colorectal cancer. Findings:  The physician reviewer found that avastin has been approved for use when combined with chemotherapy in the treatment of metastatic colon cancer. However, there is no convincing data that Avastin is efficacious when used later in the course of treatment, as is involved in this case. Further, valproic acid, a drug ordinarily used in seizure disorders, has some theoretical anti-cancer potential, but there is inadequate data demonstrating the drugs efficacy in this setting at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested nuchal translucency screening for evaluation of her medical condition.  All pregnant patients should be offered some form of aneuploidy screening.  For patients at increased risk for fetal aneuploidy due to advanced maternal age or family history, invasive testing with chorionic villus sampling or amniocentesis or noninvasive prenatal testing (NIPT) for cell-free fetal DNA may be appropriate.  For patients without these risk factors, such as this patient, options for screening include combined first trimester screening with maternal serum PAPP-A and HCG and sonographic measurement of the fetal nuchal translucency or second trimester multiple marker screening, or a combination of the two.  Combined first trimester screening has the advantage of providing results earlier in pregnancy allowing more time to make decisions regarding pregnancy options.  All told, the requested nuchal translucency screening to detect fetal abnormalities in the first trimester is medically indicated for the evaluation of this patient.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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

Nature of Statutory Criteria/Case Summary: enrollee has requested reimbursement for the wearable cardioverter defibrillator (WCD) for evaluation of the enrollees diabetes, hypertension, and non ST elevation myocardial infarction (STEMI). Findings:  The physician reviewer found that current data from multiple trials and registries have advocated the use of a WCD after an initial diagnosis of severe left ventricular dysfunction as demonstrated by an ejection fraction less than 35%. This patients ejection fraction was estimated at 15%. The American College of Cardiology (ACC) and American Heart Association (AHA) recommend against placing an implantable cardioverter defibrillator within three months of the initial diagnosis of heart failure, within 40 days of myocardial infarction, or within three months of coronary revascularization. Moreover, this patient demonstrated a high risk for sudden cardiac death due to the presence of clinical congestive heart failure. All told, the WCD provided on 4/12/17 was likely to be 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 likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Overturned

The parent of a 12-year-old male enrollee has requested coverage of Applied Behavioral Analysis (ABA) therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that ABA has been shown to be effective in treating behaviors associated with autism spectrum disorder. Treatments based on operant principles of learning are more effective in reducing maladaptive behaviors than alternative treatments. A paper by Warren and colleagues reviewed 34 studies of early intervention in autism and concluded that studies of Lovaas-based approaches and early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills (Warren, et al.). Although the most significant gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years of therapy (Sallows, et al.). The problem behaviors in this patient include poor self-regulation, aggression toward others, and inappropriate touching. In light of the patients ongoing maladaptive behaviors, ABA therapy was and is an appropriate and medically necessary modality. The patient should continue to receive 10 hours per week of ABA therapy with 1.5 hours per week of clinical supervision going forward.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee requested authorization and coverage of breast reconstruction. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollee status post previous breast reconstruction.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for biofeedback services. Biofeedback has been shown to be beneficial to the treatment of patients with urinary problems when used as supplemental therapy. In addition, data from peer-reviewed medical literature reports that biofeedback can be beneficial for patients who have failed other treatment. In this case, the patient was being managed with pessary and physical therapy. Biofeedback can help allow female patients to isolate pelvic floor accessory muscles during pelvic floor contractions, which can aide in treatment of urinary issues. Thus, pelvic floor physical therapy with biofeedback was an appropriate next step and consistent with standard of care in the management of this patients symptoms. Dumoulin and colleagues reported that group based pelvic floor muscle training was not inferior to the recommended individual pelvic floor muscle training for the treatment of stress and mixed urinary incontinence in older female patients. All told, the biofeedback services were 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 services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewer 1 is board certified in obstetrics and gynecology with subspecialty certification in reproductive endocrinology and infertility and is actively practicing. Physician reviewer 2 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewer 3 is board certified in obstetrics and gynecology 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: Medical Necessity
Decision: Overturned

The parent of an 8-year-old female enrollee has requested  for speech therapy for treatment of the enrollees speech/language condition. Findings:  The physician reviewer found that the evidence suggests that speech and language delay must be taken very seriously in young children, as the long-term consequences may be substantial. According to a Cochrane Database meta-analysis of 25 studies, approximately 6% of children have speech and language difficulties. The authors state, Whilst most childrens difficulties resolve, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior and school attainment. The authors conclude overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Bernhardt and Major concluded the following: results suggest that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for at least some children with a history of severe phonological impairment.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of his hepatitis C virus. Three physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendations for testing, managing, and treating hepatitis, 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. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. For the reasons provided, Harvoni is medically necessary for treatment of this patients medical condition.  Final Result:  Three reviewers determined that that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  Two reviewer are board certified in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition
Appeal type: Experimental/Investigational
Decision: Overturned

A 59-year-old male enrollee has requested for Hyalgan/Supartz injections for treatment of his osteoarthritis.  Findings:  Two physician reviewers found that an article by Conrozier and Vignon notes that although placebo-controlled studies are lacking, viscosupplementation for the symptomatic treatment of hip osteoarthritis (OA) may be effective. An article by Dagenais noted that the best available evidence suggests that viscosupplementation may offer symptomatic relief in patients with mild to moderate hip OA for whom other conservative therapies are contraindicated or have failed. However, the authors did note that currently this has not been determined conclusively. An article by van den Bekerom reported that viscosupplementation performed under fluoroscopic or ultrasound guidance seemed to be an effective treatment and may be an alternative treatment of hip OA.