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

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for Mavyret . The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis C virus.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 non-cirrhotic treatment-naive genotype 3 patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage. trial showed a 95% cure rate with eight weeks of treatment guidelines showing reduced survival with delayed treatment For these reasons, the requested treatment with Mavyret is supported as medically necessary for the treatment of the 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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for one additional speech therapy session per week (total of two sessions per week) for treatment of the enrollees delayed receptive/expressive language secondary to autism spectrum disorder. Findings:  The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the requested additional speech therapy session. Children with autism benefit with improved receptive language skills with the use of an AAC device. The medical literature shows that the use of AAC device can improve verbal output in children with autism. The study by colleagues looked at the challenges with assessing language in children with severe speech problems. The authors reported that testing using an AAC device may more accurately provide information on cognitive and receptive language skill. In this case, given the patients current language ability he is expected to benefit from the AAC device. Moreover, the use of an AAC requires consistency and experience. Thus, two speech therapy sessions per week is clinically indicated for this patient to work on his use of the AAC device. For the reasons stated, one additional speech therapy session per week (total of two sessions per week) is medically necessary for treatment of the patients medical condition. 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 board certified in pediatrics with sub-specialty certification in developmental and 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: Urgent Care
Decision: Upheld

A 37-year-old female enrollee has requested for emergency services request the services at issue were  required on an emergent basis. Findings:  The physician reviewer found that review of the  documentation demonstrates that the patient had flu-like symptoms and her vital signs were normal. She did not have physical evidence of meningitis and it was documented that the patient was not in pain at the time she was seen. Further, there was no evidence of respiratory distress. All told, the patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his or her health.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz tablets, 90 per month.Findings: Two out of three physician reviewers found that the requested medication, Xeljanz  tablets, 90 per month, is likely to be more beneficial than any other available standard treatments for the patients medical condition.Alopecia areata is an autoimmune disorder that causes hair loss in the scalp and can progress into alopecia universalis. It has been noted that the higher the percentage of surface involvement, the more aggressive the treatment is. Researchers have published an algorithm that recommends topical and oral steroids with minoxidil, sensitization, JAK inhibitors or prostheses with greater than 50% scalp involvement. Studies show, the consensus for preferred second-line agent was achieved in one of eleven questions. This question was, `[I]f all treatments were equally reimbursed, JAK inhibitors would be the ideal choice of systemic therapy in adults`. In this case, the patient has a longstanding history of alopecia areata and demonstrated alopecia universalis. When Xeljanz treatment was initiated, the patient exhibited significant improvement in scalp and facial hair regrowth. He continued the medication for about one year and then stopped. Upon follow up, the patient complained of more hair loss upon cessation of Xeljanz. The patient has completed and failed topical and oral steroid therapy and has a history of doing well on Xeljanz. Thus, the patient has a history of significant improvement while on Xeljanz, which is now waning after being off of the medication for about three months. Under these circumstances, the requested medication, Xeljanz tablets, 90 per month, is likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested medication is likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in dermatology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are 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: An enrollee has requested reimbursement for bilateral digital breast tomosynthesis  for the enrollees breast cancer screening. Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts.  In this particular patient, her breast tissue was described as very dense.  While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: The reviewers determined that the service at issue was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers are board certified in diagnostic radiology 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

A 35-year-old female enrollee requested authorization and coverage of infertility services. The Health Plan denied the request indicating that the requested services are 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 services are medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with low back pain with lumbar radiculopathy. The patient reported difficulty ambulating in stores and difficulty completing tasks. Physical examination findings included the patient being able to walk without antalgic gait. Tenderness to palpation was noted over the lower back and paraspinal muscles. An occupational therapist noted that the patient did not require a mobility device in her home or for short distances in the community. The patient did not have a cane, walker or wheelchair. The provider noted that the patient was able to negotiate the stairs multiple times per day. The patient reported that she planned to keep the scooter in her car as her apartment is on the second floor and she does not have an elevator. The patient reported that she is taking an extended trip to Europe and needs a power operated vehicle. The provider noted that the patient does not have any intent or need to power operated vehicle for instrumental activity of daily living tasks, only community needs. The patient has requested authorization and coverage for a motor scooter for use in or outside the home. The Health Plan denied the request and reported that the requested equipment is not medically necessary for the treatment of this patient. At issue in this case is whether a motor scooter for use in or outside the home is medically necessary for the treatment of the patients medical condition. Researchers reported, Recent research including meta-analyses have clearly underlined the negative impact of seated occupational activities on overall mortality. In this case, there were no indications that the patient has mobility limitations that cause her to be unable to perform activities of daily living. Physical examination findings do not demonstrate significant neurological deficits or gait abnormalities. The provider noted that the patient was able to negotiate stairs multiple times daily. There is no documentation that the patient has undergone a trial with a power mobility device, indicating she can safely navigate a power mobility device. The medical evidence does not support the requested equipment in this clinical setting. Therefore, a motor scooter for use in or outside the home is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for continuation of tolerance induction program. The patients provider has recommended treatment with oral immunotherapy for food allergies. Currently, the American Academy of Allergy Asthma and Immunology (AAAAI) does not recommend oral immunotherapy as a standard of care treatment for patients with food allergies due to uncertainty whether the potential therapeutic benefits outweigh the risks of treatment (Nowak-Wegrzyn, et al.). Although several studies have reported positive outcomes, according to the AAAAI, the interventions and endpoints used in clinical trials are inconsistent and do not demonstrate that oral immunotherapy is superior to allergen avoidance. Furthermore, there is significant potential for adverse events including oropharyngeal, respiratory, and gastrointestinal symptoms (Scurlock). Therefore, the requested continuation of tolerance induction program is not 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 services are 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 services are 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 allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in allergy and immunology and is actively practicing. Physician reviewer 3 is board certified in allergy and immunology with subspecialty certification in pediatrics 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar fusion. Findings:  The physician reviewer found that evidence based medical guideline criteria has not been met for lumbar fusion surgery at any level in this clinical setting. Guidelines typically do not recommend fusion for patients with degenerative disc disease (DDD), disc herniation, spinal stenosis without degenerative spondylolisthesis or instability, or nonspecific low back pain, due to lack of evidence or risk exceeding benefit. Fusion may be supported for segmental instability (objectively demonstrable) including excessive motion, as in isthmic or degenerative spondylolisthesis, surgically induced segmental instability and mechanical intervertebral collapse of the motion segment and advanced degenerative changes after surgical discectomy. Pre-operative clinical surgical indications require completion of all physical therapy and manual therapy interventions, x-rays demonstrating spinal instability and/or imaging demonstrating nerve root impingement correlated with symptoms and examination findings, spine fusion to be performed at 1 or 2 levels, psychosocial screening with confounding issues addressed, and smoking cessation for at least six weeks prior to surgery and during the period of fusion healing. Peer reviewed literature supports smoking cessation, as smoking has a significant impact on pseudoarthrosis rates. A study reported that the results of recent studies suggest that a patients pretreatment psychological state is a major independent variable that affects the ability to detect change in functional outcome. This patient presents with a history of worsening low back pain radiating into the bilateral lower extremities, left greater than right, with associated leg numbness, tingling and weakness. There is no radiographic evidence of spondylolisthesis or spinal segmental instability on flexion and extension x-rays. There is no discussion supporting the need for wide decompression that would result in temporary intraoperative instability and necessitate fusion. Potential psychological issues are documented, with no evidence of a psychosocial screen. This patient is reported to be a current daily smoker, with no documentation of smoking cessation. As such, the recommended guidelines for lumbar fusion surgery, at any level, have not been met. All told, the requested procedure is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested procedure 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 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: Upheld

A 42-year-old female enrollee has requested for an electric wheelchair for her who has left side weakness secondary to a stroke. Findings:  The physician reviewer found that the accepted criteria for power-operated vehicles require that the individual have a mobility limitation that significantly impairs the ability to participate in one or more mobility-related activities of daily living in the home and which is not ameliorated by an alternate gait aid or manual wheelchair (Burbaker; and Collen and Wade). In this patients case, her mobility-related activities of daily living have been accommodated through the use of a manual wheelchair as documented in her mobility evaluations. The mobility evaluation also revealed that the patient is able to safely operate a manual wheelchair. All told, a power wheelchair is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Hetlioz (tasimelteon). Findings: The U.S. Food and Drug Administration (FDA) approves the use of Hetlioz (tasimelteon) for the treatment of non-24. A study describes non-24 as a circadian rhythm disorder, occurring most commonly in blind individuals without light perception, characterized by a persistent cycle of nighttime insomnia and daytime sleepiness. The author notes that clinical trials in healthy individuals confirmed the circadian phase-shifting potential of tasimelteon, and that safety assessments indicated that tasimelteon is well tolerated. In this case, the submitted records did not include documentation supporting a diagnosis of non-24, such as actigraphy, melatonin level measurement, or a sleep diary. Given that non-24 may be confused with other causes of insomnia, in the absence of testing by an experienced sleep physician to appropriately diagnose the patient with non-24, the requested medication is not medically indicated. Therefore, Hetlioz (tasimelteon) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in sleep 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for Aranesp 60 mcg/0.3 ml syringe for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the standard practice for treatment of anemia is to try and correct iron deficiency prior to starting Aranesp therapy. Treatment of anemia with Aranesp does not reduce mortality. The main benefit of treatment is an improvement in the quality of life. The provided records indicate that the patient failed oral iron therapy but there is no evidence that a more aggressive treatment for iron deficiency was attempted. Moreover, the patients anemia could be multifactorial. There may be components of anemia related to her CKD but the evidence is lacking to indicate if she is symptomatic from the anemia. Therefore, for the reasons stated above, the medication at issue was not medically indicated for treatment of this patients anemia. Final Result: The reviewer determined that the medication at issue was 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 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 38-year-old female enrollee has requested Accolate 20mg for the treatment of her capsular contracture. Findings:  The physician reviewer found that there is a lack of recent validated research showing Accolate to be beneficial in the treatment of capsular contracture. The studies referenced above are preliminary reports of non-randomized and poorly controlled studies that show that Accolate is effective for capsular contracture. In this case, high quality, prospective, randomized studies of this treatment have not been published. The scientific quality of the studies referenced is poor. Therefore, the use of Accolate is not medically indicated for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Ketamine in liquid nasal spray for treatment of his behavioral health condition.  Findings:  Three physician reviewers found that Ketamine is an N-methyl-D-aspartate (NMDA) antagonist that has shown promise for dramatic improvement for those suffering from depression. Despite its promise, and reported success in this case, the treatment remains controversial. First, Ketamine is not approved by the United States Food and Drug Administration (FDA) for treatment of bipolarity. There are many unknowns regarding the antidepressant effect of Ketamine, not to mention its risk of treatment-induced hypomania or full-blown mania for those with bipolar disorder. There is a lack of evidence-informed practice guidelines regarding pre-treatment screening and patient selection criteria, intra-treatment recommended observational metrics, dosing schedules and treatment duration, and post-treatment follow-up. Final Result: Three reviewers determined that the requested medication 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:  All three reviewers are board certified in psychiatry 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.