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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lipectomy/panniculectomy surgery after sleeve bariatric surgery performed to remove excess skin. Findings:  The physician reviewer found that the requested lipectomy/panniculectomy surgery after sleeve bariatric surgery performed  to remove excess skin is medically necessary for treatment of the patients medical condition. According to  a study The abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus. In this case, the patient presents with evidence of a symptomatic abdominal pannus related to excess soft tissue from weight loss. Symptoms include sores, ulcers and rashes due to overlapping abdominal skin. The records document a large, symptomatic abdominal pannus in association with a ventral hernia. Based on the documentation provided for review, there is sufficient evidence supporting a functional deficit related to chronic rashes unresponsive to dermatologic management. All told, the request for a lipectomy/panniculectomy surgery after sleeve bariatric surgery performed to remove excess skin is medically necessary for treatment of the patients medical condition.Final Result: The reviewers determined that the requested surgery is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician 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.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 48-year-old woman who was first diagnosed with breast cancer in June 2004. At that time she was found to have a poorly differentiated invasive ductal adenocarcinoma, 2cm in size. Estrogen and progesterone receptors were negative. HER2-neu assay was also negative. Surgical options and chemotherapy were recommended to the patient but she declined, preferring instead to pursue holistic therapies.In October 2004, the patient was found to have diffuse bone metastases, as well as liver metastases. She elected to pursue non-conventional treatment in Germany. Currently, the patient has requested therapy with Herceptin, which has been denied by the Health Plan on the basis it is not medically necessary for treatment of the patients condition.Herceptin is an antibody with real usefulness in the treatment of metastatic breast cancer and has very low toxicity. However, its efficacy completely depends upon the presence of over expression of the HER2 gene by the cancer cells. Such positivity is only present in about 25% of breast cancers. Given that the patients cells do not demonstrate over expression of the gene, Herceptin will not be of any value in her treatment and therefore, is not clinically indicated. Accordingly, I have determined that 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nexlizet tablets. Findings: The U.S. Food and Drug Administration (FDA) approves the use of Nexlizet (generic name bempedoic acid/ezetimibe) tablets as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia or established atherosclerotic cardiovascular disease who require additional lowering of low-density lipoprotein (LDL) cholesterol. However, there is a lack of randomized, blinded clinical studies establishing the long-term clinical outcomes and safety of Nexlizet in patient management. The American College of Cardiology (ACC) and American Heart Association (AHA) guidelines on the management of blood cholesterol do not define the role of Nexlizet in this clinical setting. Therefore, Nexlizet tablets are 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 cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a 5-year-old female enrollee requested authorization and coverage of speech therapy for the treatment of delayed speech.  The Health Plan denied the enrollees request indicating that the requested therapy 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 services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested Genotropin growth hormone (GH) therapy for treatment of the enrollees short stature. The physician reviewer found that this patient has failure to thrive and constitutional delay in association with a chronic inflammatory condition. Although his testing revealed a peak GH response of less than 10 ng/mL to provocative testing, such testing has poor specificity for the diagnosis of GH deficiency in a patient with delayed puberty who is also underweight. In addition, a low IGF-1 level in a patient who is underweight is not specific for GH deficiency. There is also a lack of biochemical evidence that this patient has other pituitary deficiencies to raise concern about a broader diagnosis of hypopituitarism. The primary cause of this patients growth failure and delayed puberty is poor weight gain, which may be related to his chronic inflammatory condition. His pattern of continued fall-off in weight and low weight-to-height ratio is not consistent with a diagnosis of GH deficiency as the primary diagnosis. The fact that the patient has not responded well to GH treatment and recent height standard deviation score is lower than the pre-treatment height score suggests that other causes and treatments of his growth failure be considered, and continuation of Genotropin GH therapy is not medically necessary. 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 pediatric endocrinology 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 enrollee has requested proton beam radiation therapy for treatment of his medical condition.  Findings:  Three physician reviewers found that proton beam radiation therapy has been shown to be well suited to treat targets near critical structures, especially at the base of the skull. However, until proton beam radiation therapy is more fully developed and tested, it will be difficult to establish whether proton beam radiation therapy may be equivalent to photon intensity modulated radiation therapy (IMRT) in treating full head and neck cancer. At this time, further clinical data through prospective clinical trials are needed regarding cases in which the target is the primary volume located near critical structures. There are dosimetric advantages to using proton therapy over IMRT in many situations. However, in this clinical setting proton beam radiation therapy is not likely to be superior to IMRT outside of compelling dosimetric data. As such, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any standard treatments.  Final Result: Three 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:   All three reviewers are board certified in radiation oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a six-year-old male enrollee has requested for sensory integration therapy for treatment of the enrollees autism spectrum disorder.   Findings:  Two physician reviewers found that there are minimal statistically significant peer-reviewed studies that show consistent and sustainable effect and benefit from sensory integration therapy. Better-controlled studies are necessary before sensory integration therapy can be considered a proven effective therapy for the treatment of autism. Without further investigation and research, sensory integration therapy remains an investigational therapy of unproven benefit. It is not considered a standard or primary intervention for the treatment of autism.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 42-year-old female who has a history of long-standing migraine headaches and comorbid chronic back problems and depression. The medical records indicate that she has been tried on a variety of medications in an attempt to control her frequently occurring migraine headaches. She has requested an increase in her monthly Imitrex prescription from 9 to 18 tablets. The Health Plan has denied this request indicating the requested prescription increase is not medically necessary for treatment of the patients migraines. Review of the submitted medical records indicates the patient requires vigorous prophylactic treatment for her headaches. The requested quantity of Imitrex is likely to result in rebound headaches. This condition is frequently noted in patients who take large quantities of medications aimed at the acute treatment of migraine headaches. Further attempts at prophylactic headache treatment are medically indicated and likely to be more effective than the requested regimen. Therefore, I have determined the requested prescription increase 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 the medication Epclusa for treatment of the enrollees hepatitis C virus.  Findings: The physician reviewer found that according to the 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 genotype 3 patients, who have failed Sovaldi/ribavirin regimens should be treated with Sovaldi/Daklinza and ribavirin for 24 weeks. The AASLD/IDSA guidelines also support re-treatment with Epclusa and ribavirin. This is based on higher cure rates with use of Epclusa and ribavirin rather than Epclusa monotherapy (Pianko, et al). Although hepatitis C treatment is needed, Epclusa is not supported as medically necessary over Sovaldi with Daklinza for the treatment of this patients hepatitis C infection. As such the requested Epclusa treatment is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested Epulsca medication, in lieu of Sovaldi and Daklinza, 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 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

A 52-year-old female enrollee has requested for continued stay at UCLA Neuropsychiatric Hospital for treatment of her behavioral health problems. Findings:  The physician reviewer found that the patient was noted to have specific medical issues (diabetes mellitus and herpes zoster). The patient had two other admissions during an approximately six-month period. She needed an additional period of acute hospital care before it was safe to place her in a less intensive level of care, such as a partial hospitalization program.
Appeal type: Experimental/Investigational
Decision: Upheld

A 29-year-old male enrollee has requested for a wireless capsule endoscopy for evaluation of his abdominal pain. Findings:  Three physician reviewers found that chronic abdominal pain is a common complaint. In many cases, even an extensive workup does not reveal the cause of the pain. WCE is a new method for visualization of the entire small bowel. There are no randomized controlled trials in peer-reviewed journals pertaining to WCE for abdominal pain. In one study by Bardan, et. al., 20 patients with chronic abdominal pain of 6-96 months' duration were enrolled in the study. They had had an extensive diagnostic workup, which was negative. WCE was performed in all patients. Imaging of the small intestine was excellent and the colon was reached in 16 patients. In 14 patients the study was completely normal; in six patients the procedure revealed findings that were considered to be clinically insignificant. All patients tolerated the capsule well and had no adverse effects. WCE did not seem to have any significant clinical value in the evaluation of patients with obscure chronic abdominal pain. In another study by Tatar, et. al., WCE was most effective in evaluation of patients with anemia (61%) and diarrhea (36%), and least effective in patients with abdominal pain (17%).
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a 12 week course of Harvoni for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested medication. Harvoni carries the highest American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendation of Class I, Level A for treatment of HCV patients. In this case, there is documentation of progressive hepatic fibrosis. His fibrosis score meets classification per AASLD/IDSA guidelines as High Priority for medically necessary treatment. Although Viekira Pak is the Health Plans preferred therapy, Harvoni is medically necessary in this clinical setting given the patients multiple prescriptions and their drug-drug interactions with Viekira Pak. 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 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 Synvisc-One injection series in both knees. An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. Guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where everything else has been tried and the options are limited. In this case, the patient has benefitted from viscosupplementation. Furthermore, he has tried and failed NSAIDs. He is a diabetic and cannot take corticosteroid injections. There is sufficient support for the requested services in this patients case. Therefore, the requested Synvisc-One injection series in both knees is medically necessary for the 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 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: Urgent Care
Decision: Upheld

A 38-year-old female enrollee has requested for urgent care services for treatment of her sore throat.  Findings:  The physician reviewer found that the patients symptoms did not meet prudent layperson criteria for urgent or emergent care. A prudent layperson with an average knowledge of medicine and two days of sore throat, cough and nasal congestion would not reasonably expect the absence of immediate care to jeopardize their health. This patient could have been safely evaluated on a non-urgent/emergent basis.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested  speech therapy for treatment of the enrollees developmental delay with a speech delay.  Findings:  The physician reviewer found that this patient is significantly delayed in the development of speech. A speech assessment by the Health Plans speech pathologist found the patient to be at least one year delayed in speech development. The effectiveness of speech therapy in the young child is emphasized in the available peer reviewed medical literature. Law et al. reports that children with speech delay can be readily treated, as confirmed in a review of multiple medical journal articles. Gorhus-Brower specifically examines speech-delayed children who do not have cognitive deficits and points out that such patients are ideal candidates for successful speech therapy.   The patients condition has clearly been established, the Health Plans speech pathologist noted a speech delay of at least one year, and the patients developmental pediatrician has recommended an intensive speech program. In this patients case, speech therapy would be considered the standard of care in treating her speech delay.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a seven-year-old male has requested sixty-five hours per month of direct applied behavioral analysis (ABA) treatment and six hours per month of supervision for treatment of his autism.   Findings:  The physician reviewer found that the medical literature strongly supports the treatment of autism with ABA therapy. ABA is an intensive behavioral intervention program that was first reported by Lovass in the 1970s. The literature pertaining to ABA therapy has documented substantial improvement in motor, verbal, and social interactive skills in autistic children.  Myers and colleagues state: The effectiveness of ABA-based intervention in ASDs has been well-documented through five decades of research by using single-subject methodology and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings. Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. That ABA therapy is effective has been proven in multiple controlled studies including the references cited above. This patient has been diagnosed as autistic and ABA therapy remains the documented therapy of choice in this setting.Although this seven-year-old autistic patient has also been assessed with intellectual disability, the documentation reveals evidence of benefit from the extensive ABA therapy that he has received to date. He has shown improvement and has met some of the ABA goals. The patients age and intellectual disability are not deterrents to ABA therapy. The alternative of transitioning to special education and school-room socialization is not an adequate substitute for ABA therapy. The customary practice within the neurological medical community would be to continue ABA therapy in this setting.