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

Nature of Statutory Criteria/Case Summary: Anenrollee has requested authorization and coverage for Zepatier 50-100 mg tablets for 12 weeks. 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 recommendation applies to all patients, regardless of fibrosis stage. Additionally, this patient has joint pain with positive cryoglobulinemia testing and patients with symptomatic extrahepatic manifestations are prioritized for treatment per the AASLD/IDSA guidelines. In addition, the guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent . The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment . All told, the requested treatment with Zepatier 50-100 mg tablets for 12 weeks 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 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 Harvoni 90/400 mg for treatment of the enrollees chronic hepatitis C virus genotype 1a.  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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). The AASLD and IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni 90/400 mg for 12 weeks 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 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

The parent of a 5-year-old male enrollee has requested individual speech therapy for treatment of the enrollees autism and mixed receptive-expressive language disorder. Findings:  The physician reviewer found that the review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested individual speech therapy. According to the American Speech-Language Hearing Association, autistic children can benefit from speech therapy, indicating that age, either early or late in life, is not a barrier to speech therapy. In addition, Turner and colleagues performed a controlled study comparing autistic children who did and did not receive speech therapy. The authors concluded that those that did receive therapy by the age of 9 had far greater communication skills than children who did not receive speech therapy. In this case, it is medically necessary that this patient receive individual speech therapy, as his expressive language, during the 14 months of speech therapy did improve from the initial level of 2-3 word phrases to short sentences. His expressive language increased by 8 months to the language of a 2 year and 7 month old. Thus, speech therapy has resulted in a functional improvement to the point that he can now express his needs and communicate. Moreover, the patient has made significant strides in his ability to state his needs and to socially interact. Based on the medical literature cited above and the documentation submitted for review, the requested therapy is medically necessary for treatment of the patients medical condition, as he is likely to continue to benefit from this modality.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly individual therapy services. A study found a mental disorder is defined as a syndrome characterized by clinically significant disturbance in a patients cognition, emotion regulation, for behavior that reflects a dysfunction in the psychological, biological, for developmental process underlying mental functioning. Health literature indicates that functional impairment must be present in order for a set of symptoms to classify as a mental illness. Psychotherapy is effective for symptom management and reduction of relapse risk in patients with bipolar disorder.  The literature does not specify the exact frequency of psychotherapy. Typically, the patients symptom presentation dictates the frequency. This patient meets the criteria for a mental disorder due to emotional dysregulation and difficulty functioning. The records support an indication for therapy. The patient is receiving outpatient therapy on an inconsistent basis for her condition. The providers have recommended group therapy, individual therapy and dialectical behavior therapy (DBT). Given the nature of this patients issues, weekly individual therapy services are medically necessary for treatment of this patient. 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 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

Nature of Statutory Criteria/ Case Summary:  The enrollee has bilateral lower extremity pain due to myofascial pain syndrome. Findings: The physician reviewer found that the requested service is not medically necessary for the treatment of the enrollees medical condition.  Calf pain and spasms are exacerbated when the enrollees knees are bent in the sitting position. Other pain triggers are fatigue, dehydration, and exercises that contract posterior leg muscles. Her pain was primarily controlled with pain medications, but stretching and exercises also improved symptoms. She completed a reconditioning group, which resulted in changes to her physical functioning; such as increased activity, increased stretching, and improved body mechanics. Her physiatrist believes she has benefitted from proprioceptive-deep tendon reflex (P-DTR) therapy and feels she would continue to benefit with further treatments. According to the companys information, P-DTR is a unique neurological therapy based on neurology, biomechanics, neurophysiology, anatomy and profound research. It works directly with the central nervous system and has a logical scientific explanation for all of its teachings. It is constantly being researched, and the scope of practical application of its unique material is being expanded on a yearly basis. However, review of the literature indicates there are no clinical trials, case series, or narratives in the published peer reviewed literature that discuss P-DTR. There is a report of a conference, but it is not a structured, scientific report. There is no learned society that has published any recommendation for this method and there is no published research. A search of a nationally recognized website for complementary medicine revealed no information for proprioceptive-deep tendon reflex.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in physical medicine and rehabilitation and pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Vicodin 5 mg to be taken twice daily. On determining when to initiate or continue opioids for chronic pain, Dowell and colleagues report, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.  The guidelines further advise, Clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. Manchikanti and colleague state to establish medical necessity for opioid therapy, it is essential to have a physical diagnosis and information on inadequacy of multiple modalities of treatments including non-controlled substance therapy, physical modalities, behavioral interventions, interventional pain management techniques, and any other alternatives. In this case, the records note that the patient is managed on Norco. Both Vicodin and Norco contain hydrocodone as the active opioid agent, with the main difference being that Vicodin is formulated with a higher dose of acetaminophen compared to the Norco, and there is a lack of evidence that one medication is superior to the other in terms of clinical efficacy in the treatment of pain. Given the lack of evidence in current medical literature showing that any one opioid is superior to another, and a lack of documentation reporting that any specific allergy or adverse drug reactions to Norco, the requested medication is not medically indicated. Therefore, Vicodin 5 mg to be taken twice daily 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 49-year-old male enrollee has requested authorization and coverage for substance related addictive disorder treatment at a residential treatment center. The Health Plan has denied this request indicating that the requested treatment was not medically necessary for treatment of the enrollees alcohol dependence.The submitted documentation supports the medical necessity of the requested service. The American Psychiatric Association treatment guidelines for substance use disorders recommends that residential treatment or similar care higher than outpatient, is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use. lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting.A patient requires safe and stable living environments in order to develop their recovery skills thus qualifying for American Society of Addition Medicine Level III treatment at least, i.e. residential or inpatient treatment similar to what the patient received at the facility. Patients conditions wax and wane: a relatively positive documentation by one person on one day does not indicate spontaneous cure or that the patient is in the clear, it simply denotes progress and that treatment is working, which is an indication to continue, not cease treatment.The purpose of detoxification is to make the patient physically stable and safe. Rehabilitation is the essential component that should follow detoxification to help the patient maintain sobriety and reduce risk of relapse, and with rehabilitation typically a 28-day stay. Residential treatment was in accordance with generally accepted standards of medical practice; clinically appropriate for the patient's illness, not more costly than an alternative service for treatment of the patients condition, and is therefore medically necessary.Final Result: The reviewer determined that the requested service was 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 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 four-year-old female enrollee has requested speech therapy and occupational therapy for the treatment of the enrollees autistic disorder. Findings:  Three physician reviewers found that this patient has been receiving speech therapy in a pull-out public school setting. During this time, the patient made no advancement in language development as demonstrated by two testing agencies. Myers and colleagues noted that the low intensity pull-out speech therapy delivery model is often ineffective. Speech therapy is medically indicated and appropriate for this patient, and Goldsteins paper cites the success of such programs. Myers and colleagues also noted that occupational therapy for autistic children is difficult to research due to difficulties in setting up double-blinded studies. In this patients case, occupational therapy is medically indicated at this time, and the need for continued occupational therapy should be evaluated in one year.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for H.P. Acthar Gel (80 Units twice weekly). This patient presents with minimal change disease per April 2020 renal biopsy. Her provider has recommended retreatment with Acthar Gel give her prior positive response and failure of CellCept, prednisone and rituximab. Madan and colleagues evaluated 37 patients treated with Acthar Gel and found that proteinuria reduction of 30% or greater was shown in 81.1% of patients, and 62.2% showed 50% or greater proteinuria reduction. In addition, the authors observed that the proteinuria responses were greatest in minimal change disease. The authors concluded that, Acthar gel may meet an important treatment need in patients with treatment-resistant nephrotic syndrome in response to first-line therapies, patients unable to tolerate first-line therapies, and in patients with advanced disease. As this patient has undergone treatment with first-line treatment including prednisone, as well as CellCept and rituximab, she is a candidate for treatment with Acthar Gel, which is indicated for patients who are refractory or do not tolerate first-line therapy options. For these reasons, the requested H.P. Acthar Gel (80 Units twice weekly) 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 internal medicine with subspecialty certification in nephrology 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

A male enrollee has requested authorization and coverage for 4Kscore blood test. The 4Kscore test is a blood test that incorporates four prostate-specific kallikrein assay results and clinical information into a proprietary algorithm to calculate an individual patients percent risk for aggressive prostate cancer on prostate biopsy. The 4Kscore blood test is intended to be used in a patient with an abnormal PSA who is being considered for initial or repeat prostate biopsy to identify the risk of high-grade prostate cancer. The test result provides percent risk for detecting high-grade prostate cancer on subsequent biopsy. However, the use of 4Kscore is not considered clinically appropriate and generally accepted standard of care in routine screening for prostate cancer in men. In addition, this patient has a rising PSA and was recommended to undergo a prostate biopsy, which is considered the standard of care for management of patients with rising PSA. For these reasons, the requested 4Kscore blood test is not supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested testing is 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 urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 42-year-old female enrollee has requested coverage for a MRI of the breasts for evaluation of her medical condition.  Findings:  Two physician reviewers found that this patient has a positive family history of breast cancer in her grandmother who was diagnosed at the age of 55. The patient underwent aspiration of a left breast cyst two years ago. Clinically, the patient had areas of palpable thickening within both breasts.  A diagnostic mammogram, performed a year later showed dense breast tissue with no evidence of malignancy.  A bilateral breast ultrasound performed in conjunction with the mammogram showed a benign finding within the right breast and no suspicious findings. A follow-up mammogram was recommended in one year.  The patients provider has requested a bilateral breast MRI which was denied by the Health Plan. In regards to a screening MRI of the breasts, this patient is not at high risk of developing breast cancer in her lifetime using the Gail Model (a breast cancer risk assessment tool).  Using the Gail Model, this patients lifetime risk for developing breast cancer is 8.6%.  It is well documented in the medical literature that yearly screening breast MRI is medically appropriate for patients with a calculated life time risk of greater than 20%. However, this patients calculated risk for developing breast cancer is significantly less than 20%. The American Society of Breast Surgeons recommends breast MRI as part of annual breast cancer screening, in addition to mammography, for patients at very high risk for developing breast cancer, especially those with suspected or proven deleterious mutations of BRCA 1 or 2, patients with a history of radiation therapy to the chest wall and others with a 20% or greater lifetime risk of breast cancer. The patient has no history of a positive BRCA mutation in herself or in a first degree relative. The patient has no history of radiation to the chest wall. Therefore this patient does not meet the established guidelines for a screening MRI of the breasts. Additionally, this patient had an unremarkable diagnostic evaluation with mammogram and breast ultrasound.  The patient has no recent or prior diagnosis of breast cancer, no history of positive axillary nodes and the patient has no breast implants.  This patient does not meet the established criteria for a diagnostic breast MRI. The use of MRI as a screening modality in this clinical scenario is not supported by peer-reviewed scientific data. In the absence of scientific evidence demonstrating that a screening MRI is likely to be of clinical value in this setting, the proposed MRI remains of unproven efficacy.
Appeal type: Medical Necessity
Decision: Upheld

A 31-year-old female enrollee has requested modafinil (Nuvigil/Provigil) for treatment of her daytime sleepiness. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication. There is a lack of objective documentation submitted for review that shows the patient has a sleep disorder. There is no documentation that demonstrates the patient has sleep apnea, idiopathic hypersomnia, narcolepsy or a shift work sleep disorder. The patients reports of teaching in the afternoon and performing research at night does not meet the criteria for shift work sleep disorder which is documented in patients who work rotating shifts. Moreover, there is no objective documentation that shows the patient has any of the U.S. Food and Drug Administrations (FDA) approved indications for modafinil, which include narcolepsy, obstructive sleep apnea and shift worker disorder. Finally, the documentation indicates that the patient is treated for depression, which is frequently associated with fatigue. However, fatigue is not a clinical indication for modafinil. Therefore, the medical necessity of the requested medication has not been established in this clinical setting.