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

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for the OncotypeDx Breast Cancer Assay testing. The OncotypeDx Breast Cancer Assay recurrence score can be considered in select patients with one to three involved ipsilateral axillary lymph nodes to guide the addition of combination chemotherapy to standard hormone therapy. A retrospective analysis of a prospective randomized trial suggests that the test is predictive in this group similar to its performance in node-negative disease. Studies show that the use of OncotypeDx Breast Cancer Assay in well selected patients with one to three positive nodes. This patient is postmenopausal with involvement of one node and is ER and PR positive and HER2 negative. Thus, she meets the criteria for testing. For these reasons, the OncotypeDx Breast Cancer Assay was was medically necessary for evaluation of this patients breast cancer. Final Result: The reviewer determined that the testing at issue was 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 internal medicine with sub-specialty certification in medical oncology 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 patient is a 43-year-old woman with a several year history of chronic neck, shoulder and arm pain. She has previously failed treatment with Neurontin, Cymbalta, trazodone and multiple other medications. The record indicates she has also failed cervical spine surgery and has brachial plexus neuropathy. The patient was taking high doses of narcotic pain medications and finds that Lyrica, 75mg twice a day, has moderately reduced her pain and enabled her to decrease the narcotic medications. The patients request for authorization of Lyrica was denied by the Health Plan based upon a determination that it is not medically necessary.The patient has long-standing chronic pain with neuropathic features. She has failed to respond to the usual mediations and finds moderate relief with Lyrica. Lyrica is often utilized by neurologists and pain management specialists as a first-line agent for the treatment of a wide range of neuropathic pain syndromes. Continued treatment with Lyrica is beneficial to the patient and medically appropriate in this instance. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a consultation for proton beam radiation therapy. The National Comprehensive Cancer Network (NCCN) guidelines on the treatment of breast cancer  do not endorse the routine use of proton therapy. Per the medical literature, there is a lack of clinical data suggesting that proton beam radiation therapy is associated with a clinical benefit in the treatment of breast cancer. In a majority of cases, an acceptable cardiac and lung dose may be achieved using intensity modulated radiation or three-dimensional conformal techniques, along with the use of deep inspiratory breath holds during treatment, moving the heart away from the chest wall. Therefore, a consultation for proton beam radiation therapy is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service 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 radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the treatment plan recommended for the treatment of the enrollees metastatic breast cancer. Findings:  The physician reviewer found that the first line therapy for patients who have been diagnosed with metastatic breast cancer is chemotherapy. The choice of chemotherapy is dependent upon the presence or absence of estrogen/progesterone receptors and/or HER2. The guidelines summary suggest the following: (1) There are reports that suggest that 15% of recurrent lesions may have discordant ER status and therefore biopsy is recommended. (2) If ER status is positive, then current treatment guidelines suggest hormone/endocrine based therapy and reserving chemotherapy for patients who appear to be refractory to estrogen therapy. (3) If greater than 12 months from the conclusion of hormone based therapy, then hormone therapy is indicated. If less than 12 months, then an alternative hormone therapy should be considered. (4) If recurrent disease is local, then surgery or radiation should be considered. (5) If recurrence is hormone receptor negative and associated with symptomatic visceral metastasis, then chemotherapy should be considered. In this patients case, she has developed recurrent disease three years into her adjuvant treatment.  Accordingly, the guidelines would suggest that alternate endocrine based therapy should be considered. The medical record provided by the in network oncologist indicates that they are recommending chemotherapy. On the other hand, the out of network oncologist is recommending an alternate endocrine based therapy which has less side effects. Recommended treatment plan is in line with current treatment guidelines. Therefore, the treatment plan specifically recommended is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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: An enrollee has requested authorization and coverage for autonomic testing for evaluation of the enrollees medical condition. Findings:  Two of the three reviewers found per the medical evidence, POTS is an indication for autonomic testing.  This patient also has Sjogrens syndrome which is also known to cause autonomic dysfunction.  Autonomic testing is necessary to understand the severity of the condition.  Understanding the severity of the condition would help determine the intensity of the supportive and medical therapy that would be required.  Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in neurology 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

The representative/parent of a 21-year-old male enrollee has requested applied behavioral analysis (ABA) for treatment of the enrollees autism. Findings:  The physician reviewer found that the medical literature strongly supports the treatment of autism with ABA therapy. ABA therapy has a 40-year record of substantially improving motor, verbal and social interactive skills in autistic children and autistic children who received ABA therapy have demonstrated significantly improved behavioral outcomes as compared to autistic children who have not received ABA therapy (Myers, et al.). Although there is limited literature examining the utility of ABA therapy in adult autistic populations, ABA therapy has been proven to be effective in multiple controlled studies and is considered to be the standard of care for the treatment of autism. The requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for morphine sulfate quick dissolve 30 mg #150 per month for treatment of her Crohns disease. Findings:  The physician reviewer found that chronic pain and chronic diarrhea can be considered palliative in nature. The step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. However, in the documentation available for review, multiple minimal requirements for opioid prescribing have not been reported. In addition, no objective treatment goals for pain and function are noted for the requested medication. The Centers for Disease Control and Prevention (CDC) states that epidemiologic studies suggest that concurrent use of benzodiazepines and opioids might place patients at greater risk for overdose. The CDC also states that when opioids are started, providers should prescribe the lowest effective dosage. Providers should use caution when prescribing opioids at any dosage, carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 or greater morphine milligram equivalents (MME) per day, and should avoid increasing dosage of 90 or greater MME per day. In this case, the patient is taking at least 165 MME per day. No medical evidence based rationale is given for this high of a MME per day by the provider when there are alternative available for morphine that work on the same receptors. Loperamide, a synthetic opiate agonist, decreases peristaltic activity and inhibits secretion, resulting in the reduction of fluid and electrolyte loss and an increase in stool consistency.` Also, there are a number of different medications used for chronic diarrhea. Moreover, behavior therapy has not been documented despite much research to support its use for pain. Finally, not all non-opioid medications classes have been optimized or tried for pain or diarrhea. 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: Upheld

The parents of a 14-year-old male enrollee requested authorization and coverage of a referral to a dermatologist for removal of a mole on the face.  The health plan denied the enrollees request indicating that the requested referral is for cosmetic services and 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 referral is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for speech therapy. The requested speech therapy is not medically necessary for the treatment of the patients autism spectrum disorder. Serial evaluations by the speech therapist indicate that the patient has plateaued in his scores on both the receptive and expressive sections of the OWLS and on the GFTA-2. While speech therapy can be beneficial to younger children on the autism spectrum, highly structured behavioral and speech therapy interventions are of limited value in the maintenance and generalization of skills in adolescents. All told, the requested speech therapy services are not medically necessary for treatment of this patients medical condition. 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 pediatrics and neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 45-year-old female who is post reconstruction of mastectomy utilizing a TRAM flap. The patient has had reconstruction of the nipple/areolar complex and mastopexy of the contralateral breast as well as some body contouring as part of her program. The patient is presently seeking authorization for further body contouring of the posterior/lateral trunk bilaterally. The Health Plan has denied the patients request on the basis that the requested procedure is cosmetic in nature and therefore, not medically necessary.Review of the submitted records reveals no medical indication for the requested procedure. The submitted documentation of the patients surgical progress demonstrates appropriate results. The patients provider has indicated that the requested liposuction procedure is not part of the patients breast reconstruction. There is no evidence of medical necessity for liposuction of the patients trunk. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 24 weeks for treatment of his hepatitis C virus (HCV). Findings:  The physician reviewer found that Harvoni for 24 weeks is not medically necessary for treatment of the patients medical condition. American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines recommend equally efficacious treatment options for patients with HCV genotype 1a or 1b infection who have compensated cirrhosis, in whom prior peginterferon and ribavirin treatment has failed. Per guidelines, daily fixed-dose combination of ledipasvir/sofosbuvir (Harvoni) for 24 weeks is recommended as a Class I, Level A rating. In addition, daily fixed-dose combination of paritaprevir/ritonavir/ombitasvir plus twice-daily dosed dasabuvir (Viekira Pak) and weight-based ribavirin for 24 weeks is recommended as Class I, Level A rating. Viekira Pak is U.S Food and Drug Administration (FDA) approved and indicated for the treatment of adult patients with genotype 1 (GT1) chronic HCV infection, including those with compensated cirrhosis. Limitation of Use: Viekira Pak is not recommended for use in patients with decompensated liver disease.  The available records do not support absolute contraindications by the patient for the use of Viekira Pak.  All told, the medical necessity of Harvoni for 24 weeks has not been demonstrated.  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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a quantity increase of Vicodin HP 10/300 mg eight tablets per day, two tablets every six hours as needed, a total of 240 tablets per month for evaluation of the enrollee's migraines. Findings:  The physician reviewer found that the current medical evidence does not support the requested medication quantity in this clinical setting. Opiates should be used sparingly, if at all, in the therapy of migraines. The chronic use of opiates may lead to medication overuse headaches as well as transformed headaches. While this patient states he is able to function better with this medication, the long-term risks are substantial. All told, the requested quantity increase of Vicodin HP 10/300 mg eight tablets per day, two tablets every six hours as needed, a total of 240 tablets per month is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication quantity 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

The parent of a one-year, nine-month-old female enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that the recommendations in the medical literature, speech therapy is indicated for patients who present with any delay greater than 25%. Extensive review of the literature including meta-analysis by Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Further, Volmar and Weisner noted that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Overall, approximately 50% of children delayed at 2 years catch up to peers by 3 years of age while children with mild to moderate disorders are most likely to resolve their delay. In addition, the authors found that children treated with early intervention services with parental interaction and teaching demonstrated stronger language skills than those who did not receive early intervention. Moreover, children who participated in speech and language therapy showed better improvement when compared to their untreated peers. Gallagher and Chiat evaluated speech and language interventions for 24 preschool children with specific language impairment. The authors reported statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an 8-month period when compared to no intervention or nursery-based intervention.The requested speech therapy is medically necessary in the treatment of this patients medical condition and should therefore be approved.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gender confirming surgery for treatment of the enrollees gender dysphoria. Findings:  The physician reviewer found that based on the medical records provided for this review, the patient has well documented gender dysphoria. She has previously undergone parts of gender transition with facial feminization surgery. Moreover, it has been well documented that she presents with real life experience in the desired role, takes hormones for the desired gender, and has undergone some feminization procedures. As noted in the literature, the surgical approach, bilateral orchiectomies and vaginoplasty, are part of the surgical transition process for male to female transition. This patient is well documented to have gender dysphoria and so, her external anatomy should be more consistent with a female than a male. Bilateral orchiectomy and vaginoplasty are consistent with the appropriate female anatomy. Each patient must be reviewed on a case by case basis to determine medical necessity. Since this patients condition will not resolve even with hormone therapy, surgical intervention to treat this patients dysphoria is medically reasonable and appropriate.  In this patients case, the medical necessity criteria has been adequately met.  All told, the gender confirming surgery is medically necessary for treatment of this patients gender dysphoria. With regard to whether the requested services are considered reconstructive in nature, the submitted documentation demonstrates that the patients condition constitutes an abnormal body structure. The requested gender confirming surgery is part of the surgical transition from a male to a female. As stated above and supported by the medical literature, the patients male genital anatomy is abnormal for a female. The male genital anatomy in a female is considered a developmental abnormality. Additionally, the surgery would contribute to a lower testosterone level and would be expected to provide a significant improvement in the patients appearance. Therefore, the requested gender confirming surgery is reconstructive in nature.Final Result: The reviewer determined that the requested services are medically necessary and are reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic 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.