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

A 67-year-old male enrollee requested authorization and coverage of hyperthermia with adjunctive low-dose radiation therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees nasopharyngeal carcinoma.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 70-year-old female enrollee has requested a WalkAide functional electrical stimulator for treatment of her hemiparalysis. Findings:  Two physician reviewers found that there is limited research on the benefits of functional electrical stimulation (FES) over use of a standard ankle foot orthosis (AFO) for foot drop. Studies performed to date have involved small numbers of subjects. In order to demonstrate the clinical need for a neuroprosthesis for foot drop, it is necessary to demonstrate that the device significantly improves gait mechanics or is significantly better tolerated than standard bracing techniques in a given individual. In the case under review, the patients gait has not been fully assessed and it does not appear that standard therapies have been exhausted. For example, bracing alternatives such as an articulated plastic AFO or double metal upright AFO, both of which allow motion to occur at the ankle, have not been tried. A double metal upright AFO is also typically used in persons who do not tolerate a direct contact brace and are at increased risk of skin breakdown. Alternatively, there is no evidence that the patient has undergone a trial of physical therapy for gait training using her current AFO in order to optimize her functional mobility. Given the limited evidence supporting the advantages of functional electrical stimulation over bracing in general for management of foot drop and the absence of documented clinical benefit over standard therapeutic approaches in the case under review, the documentation does not support the need for the WalkAide device over standard modalities.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The parent of the enrollee requested reimbursement for  partial hospitalization program (PHP) services.  The enrollee has a history of autism, anxiety, depression, attention deficit hyperactivity disorder, and Tourettes disorder. He entered the partial hospitalization program (PHP) for suicidal ideation and depression. His psychiatrist documented he required a highly structured PHP with frequent physician oversight that could be not provided by less intensive outpatient programs due to his suicidal ideation, severe family conflict, and inability to engage appropriately in social interactions. The treatment plan was for continued PHP level of care with continued psychotherapy to augment medication management.  He was at a moderate risk of eventual self-harm or harm to others. The enrollee could control unsafe behavior while in a highly structured program with supervision. The patient met criteria for partial hospitalization.Final Result: The reviewer determined that the requested service was medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and child and adolescent psychiatry and  is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old male enrollee has requested Xifaxan 550mg, three times daily, for 14 days for treatment of his small intestinal bacterial overgrowth (SIBO).  Findings:  The physician reviewer found that after a review of the literature, the standard of care is to limit the dose to 1650mg per day of Xifaxan for seven days. The data suggests that at least 1600mg per day should be given for maximal efficacy in SIBO. Overall, about 80% of patients will have a negative hydrogen breath test when performed four weeks after seven days of treatment at 1600mg. This therapy is superior to monotherapy with either metronidazole or tetracycline derivatives. Pimentel and colleagues article discussion on use of a 14 day course was conducted in a population of patients with IBS. However, the endpoints were not the proportion achieving resolution of SIBO, but of symptoms of bloating and diarrhea. Therefore, many patients likely had resolution of their SIBO, but this number was far higher than the proportion who achieved significant improvement of their IBS symptoms. This may be due to the fact that many patients have diarrhea predominant IBS that has nothing to do with the gut microbiome. All told, one week of Xifaxan is usually sufficient to resolve SIBO in the majority of patients. Overall, there is not enough data to demonstrate that two weeks is more beneficial than one week in resolving SIBO and there is no data demonstrating that the longer course is better than the shorter course for symptom improvement. Consistent with these findings, the requested medication dosage is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 53-year-old female with documented multifocal motor neuropathy. She has responded well to IVIG and reports her condition has worsened since IVIG was suspended in February 2005. The patients neurologist has recommended the patient continue with IVIG therapy. The Health Plan has denied authorization and coverage for IVIG on the basis it is not medically necessary.The patient has multifocal motor neuropathy with a positive anti-GM, antibody. Four randomized, double-blinded placebo controlled studies have shown IVIG to be effective therapy for patients such as this patient. To date, there are no other effective therapies, though Rituxan shows some promise. The patient meets medical necessity criteria for IVIG therapy. There is no scientific evidence demonstrating IVIG therapy should be limited to a two-year period. In fact, the Vucic, et. al. article shows IVIG has continued efficacy greater than seven years. For these reasons, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 45-year-old female enrollee has requested for Botox injections for treatment of her spastic paraplegia. Findings:  Three physician reviewers found that Spasticity in the hamstring muscle causes difficulty in widening of hips for access to the urethra, which is required for catheter insertion. Botox injections have been used for many years by physiatrists and neurologists to treat spasticity.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that although continuing psychiatric care and chemical dependency specialty services were indicated, the medical records submitted for review fail to demonstrate the medical necessity for the residential level of care treatment in dispute. Upon admission, the patient had a normal mental status examination. The patients physical examination was unremarkable.  There was no evidence of intoxication or withdrawal.  The patient was described as well-developed and well-nourished, and in no apparent distress. The patient was normotensive with a heart rate of 77. The patients height of inches and weight of pounds correlated with a normal body mass index of. The patient had overconsumed alcohol a few times per week while on vacation and was described as a binge drinker. The patient had not used cannabis in the month prior to the disputed service. The acute distress that led to her overdose had resolved. The patient did not endorse a history of chronic suicidality or prior attempts.  The patient described the overdose as a cry for help. The patient was happy to be alive and motivated to feel better. The patient was well-connected with her supportive parents, and had access to safe housing.  The patient was well-educated and employed. Although the patient had been treated by a psychiatrist for several years, there was no evidence that the patient had engaged in PTSD-specific therapies, more intensive psychiatric treatment settings or chemical dependency services. Further, systematic medication management, trauma-focused therapy and diagnostic psychological testing, all of which the patient received during the admission, could have been safely and adequately been provided in an outpatient-based setting. In sum, the record does not reflect that comprehensive, evidence-based services provided in a less restrictive setting would have been unsafe, inappropriate or inadequate at the time. All told, the residential treatment center services provided were not medically necessary for treatment of the patients behavioral health condition.  Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old male enrollee has requested tesamorelin acetate (Egrifta) injection for treatment of his respiratory issues and HIV-related lipodystrophy.  Findings:  The physician reviewer found that the FDA approved indication for tesamorelin (Egrifta) is for the reduction of excess abdominal fat in HIV-infected patients with lipodystrophy. Published clinical trials have indicated greater reduction in abdominal girth with Egrifta when compared with placebo. Overall, there is substantial published evidence that significant obesity can impair respiratory function in markedly obese patients (Nguyen, et al; Santana, et al; Wei and Wu). This patient was stated by his provider to be hypoxic on the basis of chronic lung disease. While we do not have pulmonary functions tests for review, the available records demonstrate the presence of significant restrictive lung disease. Weight loss and reduced abdominal fat will likely improve the patients pulmonary function. To this end, Egrifta is appropriate for this purpose and is within the FDA indication. Consistent with the clinical and practical evidence supporting the efficacy of Egrifta for reducing lipodystrophy in this patient population, the requested medication is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 58-year-old male who has requested authorization and coverage for Celebrex. The Health Plan has denied this request indicating the requested medication is not medically necessary for treatment of the patients osteoarthritis. A review of the medical documentation indicates the patient has a history of anxiety, benign prostatic hyperplasia, and degenerative joint disease. He reports gastrointestinal intolerance to ASA, Aleve, and Advil. He has not had a history of peptic ulcer disease and is not on therapy with Coumadin or corticosteroids. He was maintained on Vioxx prior to the medication being removed from the market. He has been maintained on Celebrex therapy and reports adequate pain relief without any adverse effects. There is no documentation provided demonstrating the medical necessity of treatment of the patients condition with Celebrex. The patient has not tried formulary alternatives with a low incidence of gastrointestinal symptoms (Lodine, Relafen, Clinoril, salsalate) with or without concomitant PPI use. There is no documentation in the medical literature indicating COX-II inhibitors such as Celebrex are more effective for pain control than traditional NSAIDS. The patient should undergo a trial of formulary alternatives prior to giving consideration to Celebrex therapy. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 49-year-old female who has undergone anterior cervical corpectomy and fusion for cervical spondylosis. The patient reports persistent debilitating pain beginning in December 2005. MRI showed moderate foraminal stenosis at C3-4 and mild to moderate canal and foraminal stenosis at C4-5. The patients neurological examination and electrodiagnostic studies were normal. The patient has requested authorization for repeat cervical fusion to address the adjacent segment disease and eliminate her pain. The Health Plan denied her request indicating the requested procedure is not medically necessary.The patient has a normal neurological examination and electrodiagnostic studies showed no evidence of denervation, plexopathy, ulnar neuropathy or polyneuropathy of the upper extremities. Although there is evidence of adjacent segment deterioration at C3-4 and C4-5, there is no clear indication for surgery at this juncture. A second neurosurgical evaluation and surgical opinion is a reasonable approach prior to a second cervical surgery. 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: Experimental/Investigational
Decision: Upheld

A 54-year-old male enrollee has requested right hip arthroscopy with anterior labral repair and femoral neck and acetabular osteoplasty for treatment of his right hip labral tear.  Findings:  Two physician reviewers found that the medical literature suggests that there is growing support for hip arthroscopy as a treatment modality for select young patients with labral pathology. However, hip arthroscopy is still an evolving area with regard to its use for patients such as this patient. A study indicates that patients over 45 years of age are at risk for poor outcome after hip arthroscopy(Philippon and colleagues). The procedure should not be considered until conservative options have been exhausted. This patients records do not demonstrate that he attempted adequate, conventional treatments prior to surgery. While there was a need for cardiac rehabilitation in this case, the patients exercise regimen could have been adjusted to decrease the impact on his hip.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested gene testing for evaluation of her medical condition.  Findings:  Two physician reviewers found that based on the records provided the patient presents with hyperreflexivity and sudden coronary artery dissection but no other documented manifestation of systemic connective tissue disease and normal caliber aorta and branch vessels on CT scanning.  In this circumstance of isolated spontaneous coronary dissection current expert consensus recommendations do not include screening genetic testing for generalized connective tissue disease (Tweet, et al; Alfonso and Bastante). Likewise, treatment of spontaneous coronary artery dissection would likely not change regardless of results of genetic testing performed. Therefore, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Final Result: Two reviewers determined that the services at issue were not likely to be more beneficial for evaluation 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 internal medicine with sub-specialty certification in cardiovascular disease 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:The enrollee has requested authorization and coverage for Zepatier 50/100 mg tablets for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) 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. This recommendation applies to all patients, regardless of fibrosis stage. 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. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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: The patient has requested authorization and coverage for a cystoscopy macroplastique injection. Findings:  The physician reviewer found that Gerhard and colleagues note that postprostatectomy incontinence (PPI) may lead to severe limitations and loss of quality of life. The authors further note that treatment may include fixed slings in cases of mild or moderate incontinence, adjustable devices for irradiated patients, and artificial urinary sphincters for severe incontinence. A trial of bladder neck bulking with a permanent agent may be useful prior to urinary diversion or catheterized channel and bladder neck closure, as while collagen injections may be repeatedly used after reabsorption in native bladder necks, post-operative injection sites will commonly accept only one injection. Given that PPI is not a temporary condition that is likely to resolve on its own, the requested service is medically indicated. Therefore, a cystoscopy macroplastique injection is medically necessary for the treatment of this patient. 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 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: Medical Necessity
Decision: Overturned

The parent of a 17-year-old male enrollee has requested for psychiatric residential treatment for treatment of the enrollees major depression, polysubstance dependency, conduct disorder and attention deficit/hyperactivity disorder (ADHD). Findings:  The physician reviewer found that there was no indication of suicidal or homicidal thinking, and he was not psychotic. In the residential facility, he initially appeared reasonably cooperative, but did apparently continue some use of drugs.It would not have been reasonable to manage this patient in a lesser level of care. The patient did require the structure and the 24-hour professional observation imparted in a residential facility.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Tepezza 500 mg vial. Findings:  The physician reviewer found that records provided for review document that this patient presents with thyroid eye disease and bilateral proptosis. The patients provider has recommended treatment with teprotumumab (Tepezza). The U.S. Food and Drug Administration (FDA) has approved Tepezza for the treatment of patients with active thyroid eye disease with proptosis to prevent progression. In this case, the patient has signs of active inflammation and existing proptosis. Since she has not tolerated standard therapy with oral steroids, the use of Tepezza is the next logical therapeutic option. The patients history of glaucoma places her at higher risk for optic nerve damage due to her thyroid eye disease without appropriate treatment (Betzler, et al.). Smith and colleagues noted that, In patients with active ophthalmopathy, teprotumumab was more effective than placebo in reducing proptosis and the Clinical Activity Score. Given this support, the requested Tepezza 500 mg vial (CPT J3241) 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 ophthalmology 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.