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

A 58-year-old female enrollee has requested the medication Lyrica for the treatment of her neuropathy.  Findings:  The physician reviewer found that this patient has chronic neuropathic pain, with painful polyneuropathy. She has tried Neurontin with excessive side effects. Trial of Lyrica has been beneficial, and well tolerated. The Health Plan has denied Lyrica as not medically necessary and has based their denial on the fact that the FDA has only approved Lyrica for the treatment of post-herpetic neuralgia, diabetic neuropathy pain, and epilepsy. Because of their relatively high prevalence and therefore ease of study, post-herpetic neuralgia and diabetic neuropathy are often the best studied conditions with new medication for neuropathic pain. Medications useful for treatment of diabetic polyneuropathy are often useful for treatment of neuropathic pain from other causes. Treatment in this case can reasonably be extrapolated from data and experience with diabetic neuropathy, as well as the patients experience with treatment on a sample basis.  One standard treatment for neuropathic pain has been tried and provided inadequate relief. A trial of a tricyclic agent such as amitriptyline should be pursued. However, if a trial of a tricyclic agent is ineffective or poorly tolerated, the Health Plan should provide authorization for Lyrica.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee has requested for Synvisc injections in the right knee for treatment of his osteoarthritis. Findings:  The physician reviewer found that viscosupplementation as a treatment for osteoarthritis has been found to be effective in the knee joint, as noted by Bellamy and colleagues. A course of several injections is needed, and aside from the reduction in symptoms, there may be some beneficial effect on the cartilage, as noted by Altman. The medical evidence indicates that this treatment is most suitable for patients with mild to moderate osteoarthritis and is less efficacious when employed in patients with radiologically severe arthritis, as noted by Gossec and Dougados.
Appeal type: Medical Necessity
Decision: Overturned

The father of a two-year-old male enrollee has requested speech therapy for the treatment of the enrollees condition. Findings:  The physician reviewer found that the Health Plans definition of medical necessity for speech therapy includes congenital abnormalities, therapy with specific goals and reasonable outcomes and delivery by a qualified therapist.  The Health Plan specifically excludes speech therapy that does not result in practical improvement in a measurable time frame and treatment not supported by peer-reviewed medical literature.  These requirements are medically reasonable and appropriate. The speech therapy services provided were medically necessary and indicated for treatment of this patient.  However, speech therapy beyond the dates in question are not medically necessary at this time, as the patient requires repeat evaluation to determine if the services are being effective.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Prolia (denosumab) injection. Findings: According to the American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE), Osteoporosis may also be diagnosed in patients with a T-score between -1.0 and -2.5 and increased fracture risk using FRAX. The AACE and ACE guideline further states that, Approved agents with efficacy to reduce hip, nonvertebral, and spine fractures including alendronate, denosumab [Prolia], risedronate and zoledronate are appropriate as initial therapy for most osteoporotic patients with high fracture risk. In this case, the records do not document a history of fragility fractures related to osteoporosis. In addition, the patients bone mineral density T-scores of 0.3 and -1.4 in the lumbar spine and hip, respectively, are not consistent with a diagnosis of osteoporosis. The patients FRAX score is low at 9.1% for a major osteoporotic fracture and 1% for a hip fracture, which is below the recommendations of 20% risk for a future major osteoporotic fracture and 3% for a future hip fracture to support an indication for treatment with Prolia. Based on the available records, the patient does not meet the current criteria for osteoporosis. Given these findings, the requested Prolia (denosumab) injection, is not medically necessary for 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 rheumatology 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 parent of the enrollee has requested authorization and coverage for cognitive behavioral therapy (CBT), one hour per week for 16 weeks.  Findings: The physician reviewer found that there is sufficient peer-reviewed literatures supporting CBT as effective for the treatment of anxiety disorder in patients with ASD. The results showed that CBT was slightly more effective for children without ASD, but children with ASD still improved with CBT. A meta-analysis team compared eight randomized controlled studies for CBT for the treatment of anxiety of children and adolescents with ASD. The results showed a significant decrease in anxiety with the CBT groups relative to the non-CBT groups. The authors state that Cognitive-behavioral therapy (CBT) is a first-line of treatment for anxiety in typically developing children, and there is emerging evidence that CBT can be helpful for anxiety in children with ASD. Based on the support in the peer-reviewed literature, the patient is likely to benefit from CBT therapy for treatment of his ASD and anxiety disorder. As such, the request for CBT, one hour per week for 16 weeks is medically necessary for treatment of the 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 psychiatry with sub-specialty certification in 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 a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for physical therapy. Findings:  The physician reviewer found that The physical therapy provided was not and is not necessary for treatment of an emergency medical condition. Physical therapy evaluation and treatment for a humerus fracture is a rehabilitative process, one of restoring function over weeks or months. A study compared rehabilitation that began on the second postoperative day to rehabilitation that began weeks after surgery. Their study showed a benefit to intervention that began on the second postoperative day. An intervention beginning on a time scale of days to weeks after surgery cannot be considered emergency medical treatment. In the patients case, physical therapy services are indicated for treatment of her impaired function after humerus fracture, however physical therapy services do not constitute emergency medical services. Therefore, the services at issue were not and are not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the dates of service at issue.  Final Result: The reviewers determined that the patient did not receive emergency medical services on the dates of service at issue. Credentials/Qualifications: Physician reviewer is board certified in physical medicine 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: Medical Necessity
Decision: Upheld

A 63-year-old male enrollee requested authorization and coverage of a referral to a toxicologist. The Health Plan  denied the request indicating that the requested referral is not medically necessary for treatment of the enrollees mold exposure.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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for treatment of his medical condition.  Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. In treatment-naive genotype 3 patients (regardless of interferon eligibility), therapy is recommended with Sovaldi and Daklinza for 12 weeks, or with Sovaldi and peg-interferon with ribavirin for 12 weeks. This is based on the ALLY-3 study and the BOSON trial, which showed cure rates of over 95% with either regimen (Nelson, et al; Foster, et al).  However, delay in treatment may result in decreased survival, and no alternative therapy has been approved (Jezequel, et al). For these reasons, treatment is indicated in this case regardless of fibrosis stage, and the requested treatment with Sovaldi and Daklinza is medically necessary for the treatment of this patients hepatitis C infection.   Final Result: The reviewer determined that the requested medications 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 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 55-year-old female enrollee requested authorization and coverage of revision gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary. An enrollee has requested bilateral breast tomosynthesis for the enrollees breast cancer screening.  Findings: Three physician reviewers found that the patient has a family history of breast cancer. The patient underwent a routine screening mammogram consisting of a combination two dimensional (2D) and three dimensional (3D) tomosynthesis examination. The report noted that this study was the patients baseline mammogram, and no prior mammograms were available for comparison.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  The patients breasts were described as being heterogeneously dense. The Health Plan has denied reimbursement for bilateral breast tomosynthesis.  Per the Health Plan, the service at issue was investigational for the evaluation of this patient. 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 (CT) 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 patients case, she has breasts that were described as heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. For these reasons, bilateral breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.Final Result: Three physician reviewers have determined that the service at issue was 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: All three physician reviewers are board certified in diagnostic radiology 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: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for bilateral Synvisc One injections. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients primary bilateral osteoarthritis of the knees. The submitted documentation does not support the medical necessity of the requested medication. Evidence-based medical guidelines state that hyaluronic acid injections in the knee are recommended as a possible option for patients with severe osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to corticosteroid injections. While medial and/or lateral compartment osteoarthritis is a recommended indication, there is insufficient evidence for other conditions, including patellofemoral arthritis, chondromalacia patella, patellofemoral syndrome (kneecap pain), or osteochondritis dissecans. This patient presents with a recurrence of bilateral knee pain. Functional limitations were noted in mobility and activities of daily living. Prior Synvisc One injections reportedly resulted in in pain reduction and improved functional mobility. However, there is no documentation of a specific clinical examination or discussion of radiographic findings to support the presence of medial and/or lateral compartment osteoarthritis. The treating provider documented a diagnosis of patellofemoral arthritis. Current evidence-based guidelines and literature support the medical necessity of hyaluronic acid injections for the treatment of medial and/or lateral compartment arthritis. However, the medical evidence does not support the medical necessity of these injections for patellofemoral arthritis. Therefore, the requested bilateral Synvisc One injections are not medically necessary for the treatment of the 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 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 54-year-old female enrollee has requested an additional 12 chiropractic visits for the treatment of her lower back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate measurable objective findings to support a finding of medical necessity based on efficacy of the treatment already provided. Thus, there is insufficient evidence in the records to suggest that future chiropractic services would benefit this patient. The Journal of the American Chiropractic Association and the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) indicate that the treating provider is expected to keep and maintain case records that clearly indicate the progression of care, diagnosis, clinical impressions, assessment of the patients condition and treatment effectiveness from visit to visit. This providers records do not discuss objective findings with relation to restoration of loss of function, changes to range of motion or body positioning. The records also fail to show orthopedic and neurologic assessments or pain charts and visual analogues for pain assessment and degree of pain. An x-ray report suggests the patient has a normal hip and does not indicate another reason for this patient to be treated. Without documentation of the type of chiropractic technique used for this patient or her response, the records provided do not support a finding that this form of treatment has improved the patients condition or that future chiropractic services are necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is an 11-year-old male with a diagnosis of short stature. Based on the documentation provided, it appears the patient began growth hormone (GH) therapy in March 2004. The heights of the parents have not been provided. When seen in December 2004, the patient was age 11 and had grown more than 10cm in the previous year. Prior to this the patient had generally grown at a normal rate near the third percentile. A request has been made for continued use of growth hormone therapy. The Health Plan has denied the request on the basis that the requested therapy is not medically necessary for treatment of the patients medical condition. The submitted records show that the patient had no delay in bone age, had at least one normal response to clonidine GH stimulation test (peak 18ng/ml), and two normal levels of IGF-1 and a normal GH dependent IGFBP-3 level. Thus, GH deficiency is improbable. The patient had a significant growth response to GH therapy. It seems that puberty had advanced at least to axillary odor. The patients father indicates the patient had a pre-GH therapy growth rate of less than 5cm a year and at least a doubling of that rate on GH therapy. The patients predicted adult height based upon bone age and height in March 2004 would lie in the 55-56 range. Based upon these findings, the patient does not meet medical necessity criteria for consideration of GH therapy. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for whole exome sequencing for evaluation of the enrollees developmental delay. Findings:  The physician reviewer found that whole exome sequencing has been established as medically necessary for evaluation of the patients medical condition. Whole exome sequencing is clinically indicated for this patient given his complex neurologic phenotype and epilepsy. These multi-system findings increase the likelihood of an underlying single gene disorder which can be identified by whole exome sequencing. Whole exome sequencing is the most efficient way to identify such a genetic etiology given the large number of potential conditions which can cause developmental delay, autism spectrum disorders, and epilepsy. Moreover, the identification of a specific diagnosis in this patient may provide guidance for management in the future. A unifying diagnosis may also provide insight into helpful treatments for seizures in this patient. All told, the request for whole exome sequencing is medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested testing is 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 pediatrics and clinical genetics 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 evaluation for autologous systemic immune suppression trial #NCT01445821 for evaluation of the enrollees scleroderma. Findings:  The physician reviewer found that when patients with advanced cancers have exhausted standard regimens, the National Cancer Institute Physicians Data Query recommends enrollment in a clinical trial. In this case, the patient has a terminally progressive disease that has been resistant to standard treatment options. As requested, he would be enrolled in a clinical trial testing auto-HSCT versus pulse dose cyclophosphamide for his disease but the underlying treatment modality of auto-HSCT is considered standard for advanced scleroderma. All told, enrolling this patient in the clinical trial being considered is medically appropriate. Thus, the requested evaluation for autologous systemic immune suppression trial #NCT01445821 is medically necessary for evaluation of this patients scleroderma.Final Result: The reviewer determined that the requested services are 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 oncology and hematology 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.