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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Inogen One G5 Portable Oxygen concentrator. The records provided for review document the presence of fibrotic lung disease, which supports an indication for treatment with supplemental oxygen. Use of supplemental oxygen should be adequate to meet a patients needs, while still promoting ambulation, mobility, and an active lifestyle. This patients current portable oxygenator is no longer under warranty. The device is heavy and not suitable to supporting an active and mobile lifestyle. Given the critical importance of protecting the functional status in patients with fibrotic lung disease, the requested Inogen One G5 portable oxygen concentrator is appropriate for this patient. Therefore, the requested Inogen One G5 Portable Oxygen concentrator is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 subspecialty certifications in pulmonary disease and critical care 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

A 63-year-old male enrollee has requested for intensity modulated radiation therapy for treatment of his stage IIBX lymphoma. Findings:  Three physician reviewers found that IMRT has been recommended. Comparative IMRT and 3D conformal plans were submitted. These plans indicate significant dosimetric benefits in renal and kidney sparing with IMRT versus 3D conformal radiation therapy in this case. Thus, IMRT is likely to be a more beneficial treatment alterative for this patient than the 3D conformal radiation therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female has requested surgical removal of mesh, hernia repair surgery, and surgical repair of the upper and lower intestines for treatment of her seroma.   Findings:  The physician reviewer found that this patient has undergone significant weight loss following a gastric sleeve procedure. In addition, she had a panniculectomy, which appears to have been complicated by a large seroma formation. The patient has requested surgical removal of mesh, hernia repair surgery, and surgical repair of the upper and lower intestines. However, the medical documentation does not support that these services are medically indicated. Specifically, there is no evidence in the medical record provided that the patient has had mesh implanted, has a hernia, or has an abnormality of the upper and lower intestines, for which correction is recommended or indicated. Further, the patient does not appear to have a functional deficit related to her previous panniculectomy and the documented seroma. This condition appears to have been addressed with consideration for revision of the abdomen and CT-guided drainage. From the references provided, panniculectomy is a standard treatment for excess tissue related to significant weight loss. The patient had a panniculectomy and appears to have had a relatively common complication associated with that procedure. Overall, the requested procedures do not address the issues generally related to conditions of excess, overlapping skin and subcutaneous tissue. Thus, the medical record does not provide sufficient evidence to support any of the requested procedures are indicated and the procedures requested do not address the issues that the medical record has defined for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential mental health and substance abuse treatment services for treatment of the enrollees polysubstance abuse and generalized anxiety disorder. Findings:  The physician reviewer found that the records provided for review do not support the medical necessity of residential mental health and substance abuse treatment services for treatment of this patients polysubstance abuse and anxiety. There was no evidence that the patient had any suicidal or homicidal ideations or evidence of psychosis. Further, the patient was able to conduct activities of daily living. Based on the available documentation, the patient could reasonably have been treated at a less restrictive level of care, such as intensive outpatient program (IOP) for chemical dependency and mental health treatment. 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 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: Medical Necessity
Decision: Upheld

A 77-year-old male enrollee requested authorization and coverage of the medication Avodart. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees benign prostatic hypertrophy.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old female enrollee has requested for prolotherapy for treatment of her left knee pain.  Findings:  Three physician reviewers found that the peer-reviewed medical literature, prolotherapy is not adequately supported in well designed, randomized, prospective, double-blind studies. The study by Reeves and Hassanein only evaluated a small number of knees and there was a different cohort protocol for the study group versus the control group. Uthman reviewed the medical literature from 1968 to 2002 and found a lack of convincing or reproducible evidence to support intra-articular therapies including prolotherapy as altering the course of osteoarthritis of the knee. there is a paucity of data supporting the superiority or equivalence of prolotherapy in treating osteoarthritis of the knee. Therefore, the requested therapy is not likely to be more beneficial than standard therapies in the management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old male enrollee requested  Sovaldi 400 mg, Pegasys and ribavirin for medical treatment of his hepatitis C virus (HCV).  Findings:  The physician reviewer found in many cases, using the F3 liver fibrosis score cutoff is appropriate, however in this particular case treatment with the requested medications is medically necessary. This patient is relatively young, and despite mild chronic obstructive pulmonary disease (COPD), he has an anticipated extended lifespan. Thus, treatment is recommended in this particular case. As such, based on the medical records submitted for review and the medical literature cited above, the patients request for Sovaldi 400 mg, Pegasys and ribavirin is medically necessary in this clinical setting. Therefore, the medical necessity of the requested medications has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old male enrollee has requested care rendered for treatment of his parent-child relational problem, bereavement and conduct disorder, adolescent-onset type. Findings:  The physician reviewer found that the medical necessity for treatment in a 24-hour residential setting during the time period at issue is not established. Treatment interventions during the stay reflect individual and group therapy. American Academy of Child and Adolescent Psychiatry guidelines for the treatment of conduct disorder indicate the benefit of multimodality community-based treatment and multi-systemic therapy. Other intense services, such as wraparound services and aggressive case management along with intense family interventions, have documented benefit.  Per the American Academy of Child and Adolescent Psychiatry and American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System, this patient was a candidate for treatment in a less intense setting during the period at issue. In this patients case, outpatient services were medically appropriate. All told, care rendered during the time period in question was not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with mild bronchiectasis, which was confirmed by computed tomography (CT) scan of the chest. The records document chronic obstructive pulmonary disease. He has had two episodes of acute exacerbation of his bronchiectasis with an increase in productive cough. His symptoms reportedly improved with antibiotics. The patients provider recommended utilizing airway clearance techniques to manage his sputum production.  The patient was determined by his provider not to be a candidate for manual chest physiotherapy and postural drainage due to the lack of a care provider who could assist him with this type of therapy. The patient has requested authorization and coverage for a high-frequency chest wall oscillation system. The Health Plan has denied this request and reported that the requested device is not medically necessary for the treatment of this patient. The submitted documentation fails to demonstrate the medical necessity of the requested device.  Studies noted that although airway clearance techniques and high-frequency chest wall oscillation, in particular, could increase sputum expectoration, selected measures of lung function, symptoms, and health-related quality of life, the role of these techniques in acute exacerbation of bronchiectasis is unknown. Studies noted that the impact of airway clearance techniques on individuals experiencing chest infection is unknown. Studies concluded that performing airway clearance techniques on patients with stable chronic obstructive pulmonary disease did not appear to affect flare-ups or hospitalizations. The medical evidence does not support the requested device in this setting. Therefore, the requested high-frequency chest wall oscillation system is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested device 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 pulmonary 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Zohydro ER 30 mg capsule once every 12 hours. In terms of dosage, the American Society of Interventional Pain Physicians (ASIPP) state that 40 morphine milligram equivalents (MMEs) is low dose, 41 to 90 MME is a moderate dose, and greater than 91 MME is high dose. In this case, the patient has chronic pain from lumbar stenosis and left lumbar radiculopathy per the providers notes. She has lumbar scoliosis with degenerative disc disease affecting L4-5 level. The patient is a candidate for spine surgery, but has been unable to move forward with surgery, as she is the primary caregiver in her home. She is currently actively participating in a home exercise program including yoga, which reportedly is helpful in managing her pain. The patient is currently taking Norco for breakthrough pain and her provider is using Zohydro to reduce her reliance on the short-acting pain medication. The provider documented that the Controlled Substance Utilization Review and Evaluation System (CURES) report and urine drug screens have been consistent with therapy and the patient has no documented events of aberrant drug behavior. Based upon the above listed guidelines, the patient is successfully managing her pain while also being weaned off her pain medications by her provider. She is effectively using non-pharmacologic modalities to treat her pain in addition to opioid medication and there are no signs of behavioral problems. Given these findings, the requested Zohydro ER 30 mg capsule once every 12 hours 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 anesthesiology with subspecialty 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: Experimental/Investigational
Decision: Overturned

Physician 1: The patient is a 45-year-old male who has a body mass index (BMI) of 43.3. He is 5'8` and weighs 284 pounds. He is requesting authorization for vertical gastrectomy/gastroplasty for treatment of his morbid obesity. The Health Plan has denied this request indicating the requested procedure is considered investigational for treatment of his medical condition.The requested procedure has been described in scientific literature not only as a definitive procedure but also as a staging procedure. The physiologic basis of this procedure is no different than proximal gastric bypass, which is a restrictive procedure. The proposed procedure is medically reasonable and appropriate and likely to be effective for patients such as this patient. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2: The patient is a 45-year-old male with morbid obesity and comorbidities. He has failed multiple medical treatments. He has no contradictions to surgery. He has requested authorization and coverage for vertical gastrectomy/gastroplasty, which has been denied by the Health Plan on the basis it is considered investigational.The patient has extensively reviewed his options. He does not wish to undergo a malabsorptive procedure. A gastric restrictive procedure has been recommended. The proposed procedure has an acceptable success rate with a very favorable risk profile. It is a well-established procedure with proven efficacy. Hence, it is a reasonable alternative with an adequate safety profile. Furthermore, should the restrictive procedure fail over time, a future malabsorptive procedure would not be precluded.For these reasons, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3: This patient is a 45-year-old male with a BMI of 43 and related comorbidities. He wishes to undergo weight loss surgery and believes vertical gastroplasty/gastrectomy is the most appropriate procedure for treatment of his condition. The Health Plan has denied coverage for the proposed procedure on the basis it has not been shown to be efficacious for patients such as this patient.Review of the relevant medical literature reveals there is insufficient evidence of the efficacy of vertical gastroplasty/gastrectomy. The proposed procedure has been used as a component of a staged procedure in the super obese (BMI greater than 60). It is not generally used as sole therapy in the average morbidly obese patient. Further studies are needed before vertical gastroplasty/gastrectomy can be recommended for patients such as this patient. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old male enrollee has requested cochlear implants, integrated system replacements for treatment of the enrollees hearing loss. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested device.  This patient has congenital bilateral sensorineural deafness.  The medical records noted prior successful implantation of cochlear implants.  The patients clinical audiologist has recommended that the patient be fitted with new speech processors.  However, based upon the medical records, the current speech processors are functioning adequately.  Therefore, there is no medically necessity for the requested device in this clinical setting.  All told, the requested cochlear implants, integrated system replacements are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old male enrollee has requested Neuromonics TRT treatment for the treatment of his chronic tinnitus. Findings:  The physician reviewer found that although there are anecdotal reports of benefit, the safety and efficacy of the Neuromonics Tinnitus Retraining (TRT) program has not been sufficiently established. Studies conducted to date have only involved a small number of subjects and these studies have been open. Given the paucity of data currently available, Neuromonics TNT cannot be considered medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Mavenclad (six tablets/five day dosing regimen). The U.S. Food and Drug Administration (FDA) approves the use of Mavenclad for the treatment of patients with relapsing forms of MS, including relapsing-remitting MS and active secondary progressive MS, and is generally recommended for patients who have had an inadequate response to, or are unable to tolerate, an alternate drug indicated for the treatment of MS. The American Academy of Neurology (AAN) practice guideline recommendations for disease-modifying therapies (DMTs) for adults with MS include (1) offering DMTs to patients with relapsing forms of MS with recent clinical relapses or MRI activity, (2) discussing a switch to a DMT with a lower PML risk for patients taking Tysabri who are or become JC-virus antibodypositive, especially with an index of above 0.9 while on therapy, and (3) as multiple DMTs are available, discussing switching DMT therapies for patients who experience adverse effects or complications with a DMT, including changing to non-injectable or less frequently injectable DMTs in patients who report intolerable discomfort with the injections or injection fatigue. In this case, the patient has a diagnosis of relapsing remitting multiple sclerosis. The records noted that the patient was being treated with Tysabri with a recent JC-virus antibody index of 2.26. The records noted that Gilenya was not considered due to an increased risk of PML, and that Extavia was not considered because the patient did not desire an injectable therapy. In this clinical setting, given that the AAN practice guidelines support switching the patient to another DMT, the requested medication regimen is medically indicated. Therefore, Mavenclad (six tablets/five day dosing regimen) is medically necessary for the treatment of this patient.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 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

Nature of Statutory Criteria/Case Summary: At issue in this case is whether the requested Epclusa 400mg -100mg for 12 weeks is medically necessary to treat the patients medical condition. 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 nonliver-related conditions. This patient has liver nodularity consistent with cirrhosis on imaging, as well as concern for ascites, an indicator of decompensated cirrhosis. However, the Epclusa regimen requested is not sufficient for the patients clinical presentation. The AASLD/IDSA guidelines recommend that treatment-naive genotype 1 patients with decompensated cirrhosis should be treated with Epclusa and ribavirin for 12 weeks, based on the ASTRAL-4 trial. The guidelines state that if ribavirin is not used, Epclusa must be used for 24 weeks. For these reasons, although treatment of hepatitis C is needed, the requested treatment with Epclusa 400mg -100mg for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection.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 subspecialty 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.