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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acute rehabilitation services. Findings:  The physician reviewer found that noxic brain injury, including due to cerebral hypoperfusion during cardiac arrest, has a challenging clinical course and guarded outcomes. The patient in this case sustained an anoxic brain injury due to cardiac arrest. The provider charted that the patient has experienced a protracted convalescence following multiple cardiac arrests. The patient recently started to emerge from a state of poor cognitive function. However, the patients cognitive status remains severely impaired. The records do not demonstrate that the patient is able to carryover information from one therapy session to the next. The patient has behavioral impairments, is severely physically deconditioned, and he has continued to require near total assistance for his self-care. Overall, the patient has a guarded prognosis for significant functional recovery. In this clinical setting, it is not expected that an intensive rehabilitation program will significantly improve the patients course or outcomes. The patient is not currently able to consistently participate in, tolerate, or meaningfully benefit from intensive acute rehabilitation services. Given these findings, the requested acute rehabilitation services are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation 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 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 Novolog FlexPen. Findings: The physician reviewer found that insulin analogs such as Novolog, differ from human insulin and between each other by the substitution of one amino acid of the insulin molecule. Although current rapid-acting insulin analog products have met the threshold criteria for chemical and physical stability as set by the U.S. Food and Drug Administration (FDA), these formulations are susceptible to physical and chemical degradation above room temperature than are comparable wild-type formulations. The medical literature related to biosimilar medications of non-insulin products have required studies not only related to efficacy, but also related to immunogenicity. The records provided for review in this case demonstrate that the patient requires Lantus basal insulin and Novolog meal insulin. The patients hemoglobin A1C is at goal. In this case, the patients diabetes control is at goal with current therapy. The provider indicated in the medical record that patient had failed Humalog in the past. Thus, a change of insulin to a preparation that has failed in the past is contraindicated and would place the patient at risk of losing control of their diabetes. Based on the information provided, the requested Novolog FlexPen is medically necessary for treatment of this patients medical condition. 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 endocrinology, diabetes and metabolism 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 7-year-old male has requested applied behavioral analysis (ABA) therapy for treatment of his autism.  Findings:  The physician reviewer found that applied behavioral analysis (ABA) programs have been shown to be effective in treating behaviors associated with autism spectrum disorder (ASD). Most recently, a 5-year randomized controlled study involving 48 children with autism found significant improvements in IQ, adaptive behaviors and overall autism diagnosis using an Early Start Denver Model (ESDM) interaction based on developmental and applied behavior analysis principles (Dawson, et al). In addition, a systematic review by Warren and colleagues found that Lovaas-based approaches and early intensive ABA intervention variants of the ESDM resulted in improvements in cognitive performance, language skills, and adaptive behavior skills. Further studies have shown treatments using the ABA approach to be efficacious (Rogers and Vismara). Current developmental trajectories note that behaviors in autistic children change over time and goals for intervention vary depending on the specific clinical context and age of the child. As noted by the National Research Council, ABA offers a program that is intensive, structured, individualized with explicit teaching of social skills, communication and learning to learn skills. Given this patients autistic behaviors and his level of progress in ABA treatment thus far, the ABA services provided since the date in question and forward are medically appropriate at the requested frequency of 10 hours per week.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old female enrollee has requested use of a continuous passive motion machine for the treatment of her knee, status post right knee anterior cruciate ligament reconstruction surgery. Findings:  The physician reviewer found that the medical literature contains extensive research on use of a CPM device following knee surgery. Studies have primarily focused on patients who underwent total knee arthroplasty. As noted by Brosseau and colleagues, there is no conclusive evidence demonstrating the benefit of CPM following total knee arthroplasty. A more recently published trial conducted by Bruun-Olsen and colleagues also suggested that there is no significant benefit of CPM use following total knee arthroplasty. Additionally, with respect to arthroscopic ACL repair, there are no reliable scientific data that supports the use of CPM when compared to standard treatment consisting of physical therapy alone. An early study by Noyes and colleagues concluded that no significant short- or long-term functional advantages were observed in patients treated with CPM versus those who did not receive such therapy. Further, Richmond and colleagues found no clear dose-effect for CPM following arthroscopic ACL repair. In a small trial published in 1989, Anderson and Lipscomb reported that the optimal rehabilitation post-ACL repair included electrical muscle stimulation and immobilization in flexion with early limited range of motion. The CPM group in this study did not do as well as the group that was immobilized in flexion and underwent early limited range of motion. In a small trial published in 1997, Gaspar and colleagues noted some improvements in a CPM group versus a non-CPM group at the time of hospital discharge following ACL repair, but no significant difference in outcomes at 6-month follow up. A more recent trial by Friemert and colleagues concluded that patients with active motion had better outcomes than patients treated with CPM with respect to joint position following ACL repair. Overall, the literature does not demonstrate a significant benefit from CPM following ACL repair.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a seven-year-old female enrollee has requested speech therapy for the treatment of the enrollees phonological disorder. Findings:  The physician reviewer found that the patients articulation and consonant substitution were significantly below the norms for her age. The etiology of the speech disorder was neurological in that the patient was intellectually normal and had normal motor development and speech acquisition. The difficulty is related to a motor apraxia of the tongue and palate which is a congenital neurological dysfunction. The therapist felt strongly that the disorder was treatable within a finite period. Speech therapy is medically appropriate and indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old male enrollee requested authorization and coverage of blood tests for screening purposes.  The Health Plan denied the enrollees request indicating that the requested blood tests are 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 blood tests are not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 22-year-old male enrollee has requested applied behavioral analysis (ABA) therapy for treatment of his autism.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the therapy at issue.  Autism is a highly recognizable developmental disorder firmly steeped in biological etiology. Applied behavioral analysis (ABA) is an empirically proven treatment intervention for children. ABA can also result in therapeutic gains in adolescent and adult autistic patients. Despite this patients impairment, ABA therapy has worked well for him, and the treatment both optimizes his functionality in the community thereby reducing morbidity and minimizes the risk for treatment needs in more restrictive settings. ABA therapy delivered in accordance with a comprehensive treatment plan that has identifiable goals and quantifiable objectives, and is based on thorough evaluation and evidence-based practice is a medically reasonable and appropriate intervention for this patient. The requested frequency of ABA services was and is medically necessary in light of the patients past progress and current deficits. Therefore, based on the patients clinical presentation and relevant peer-reviewed literature, the therapy at issue is safe, appropriate, and medically necessary for the treatment of the patients medical condition. In sum, the therapy at issue was and is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 26-year-old female enrollee requested authorization and coverage of a gastric bypass surgery consultation. The Health Plan denied the request indicating that the requested consultation is not medically necessary for evaluation 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 consultation is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a Repatha Sureclick Pen Injector for treatment of his medical condition.  Findings:  The physician reviewer found that in the medical literature, Stroes and colleagues reported that efficacy combined with favorable tolerability makes evolocumab a promising therapy for addressing the largely unmet clinical need in high-risk patients with elevated cholesterol who are statin intolerant. In addition, the U.S. Food and Drug Administration (FDA) has specific approved indications for treatment with the Repatha Sureclick Pen Injector. However, this patients records do not demonstrate that he is intolerant to, or has a contraindication to the Health Plans formulary alternatives. Thus, the requested Repatha Sureclick Pen Injector is not supported as medically necessary for treatment of this patients mixed hyperlipidemia.  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 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: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the bilateral balloon sinuplasty of the frontal, maxillary and sphenoid sinuses (CPT 31295 x 2 and 31298 x 2) that was performed. The Health Plan has denied the service at issue as experimental or investigational for treatment of the enrollees chronic rhinosinusitis (CRS).Findings:  Two out of three physician reviewers found that According to the American Academy of Otolarygology-Head and Neck Surgery (AAO-HNS) official policy statement, sinus ostial dilation (e.g. balloon ostial dilation) is a therapeutic option for selected patients with CRS who have failed appropriate medical therapy. Clinical diagnosis of CRS should be based on symptoms of sinusitis and supported by nasal endoscopy documenting sinonasal abnormality or mucosal thickening on CT of the paranasal sinuses. The records state that he was treated with maximal medical therapy prior to the CT scan. He had been treated in several urgent care centers and also with an extended course of antibiotics. However, there was only evidence of sinus disease in the right frontal sinus and the sphenoethmoid recess. There was opacification of the posterior ethmoids. The maxillary sinuses, ostiomeatal complex, left frontal, and the sphenoid were clear. One physician reviewer found that the medical record did not confirm an etiology of chronic sinus disease. Final Result: The reviewers determined that the balloon ostial dilation procedure of the right frontal and sphenoid sinuses (CPT 31298 x 1) that was performed was likely to be more beneficial than any available standard therapy. However, the balloon ostial dilation procedure of the left frontal and sphenoid sinuses (CPT 31298 x 1) and maxillary sinuses (CPT 31295 x 2) were not likely to be more beneficial than any available standard therapy. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in otolaryngology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested proton beam radiation therapy for treatment of her medical condition.   Findings:  Two physician reviewers found that the difference between proton and photon irradiation is that the protons stop abruptly in the tissue (Bragg Peak) so there is less exit dose through normal tissue. The use of proton therapy is an accepted radiation technology, that has proven efficacy and tolerability as it is simply another means to deliver radiation. Certain conditions such as base of skull chordomas and chondrosarcomas, and pediatric central nervous system (CNS) malignancies are probably best treated with proton therapy, due to the sharp dose fall off, allowing high dose delivery to the tumor, while relatively sparing the neighboring normal tissue. There is abundant data on proton therapy for sinonasal cancers as well, and proton therapy is an accepted treatment modality. While proton therapy is not an accepted standard outside of sinonasal cancers abutting critical structures or in the setting of re-irradiation of targets abutting critical CNS structures, both of these situations apply in this patients case. In general, proton therapy is more effective in sparing the normal tissues in and around the base of skull. Thus, the requested proton beam radiation therapy is likely to be more beneficial in treating this patients squamous cell carcinoma than any other available standard therapy.  Final Result: Two reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intravenous immune globulin infusion. There is sufficient support for the requested services in this clinical setting. The National Comprehensive Cancer Network guidelines indicate that prostate radiation is necessary for patients with metastatic prostate cancer. Researchers performed a recent meta-analysis and concluded that radiation therapy should be considered for men with metastatic hormone-sensitive prostate cancer with a low metastatic burden. This patient has local symptoms due to his prostate cancer and would derive a palliative benefit from prostate radiation. Intensity modulated radiation therapy techniques are necessary to reduce the radiation to the surrounding organs, including the bladder and rectum. Therefore, intensity modulated radiation therapy 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 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 Harvoni 90-400 mg, one tablet daily for 12 weeksFindings: 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 all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 infection regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment . For these reasons, the requested treatment with Harvoni 90-400 mg, one tablet daily for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication regimen 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested trigger point injections for treatment of his multiple joint pains.  Findings:  The physician reviewer found that according to Simons and Travell, trigger points are discrete, focal, hyper-irritable spots located in a taut band of skeletal muscle. In this patient, there is inadequate documentation that trigger points were identified upon examination. Trigger points are painful on compression and can produce referred pain, referred tenderness, motor dysfunction, and autonomic phenomena (Simons). Simons and Travell outline the following method for providers to identify a trigger point as opposed to another diagnosis: conducting a focused medical history; identifying a meticulous history of the onset of pain; detailing the pain pattern; demonstrating the restricted range of motion; and placing a finger unerringly on the exquisitely tender trigger point. This method of documentation has not been clearly documented in the submitted records. Furthermore, based on the documentation provided, it does not appear other less invasive treatment modalities have been attempted. As trigger point injections utilize an injectable solution they pose increased risk to this patient who presents with elevated transaminase and lactic acid dehydrogenase (Chan, et al). For these reasons, the requested trigger point injections are not medically necessary for treatment of the 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 anesthesiology with sub-specialty certification in pain management 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 12-year-old female enrollee has requested Luprolide Acetate Depot (Lupron) for the treatment of the enrollees Russell-Silver Syndrome. Findings:  The physician reviewer found that the additional administration of Lupron is clinically sound since the patient is already in established puberty. The addition of Lupron to the patients growth hormone regimen will delay full puberty and closure of the patients epiphysis. Since the patient meets FDA criteria for growth hormone, the concomitant use of Lupron is clinically appropriate and medically indicated.