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

A 55-year-old female enrollee requested authorization and coverage of bilateral breast reduction. The Health Plan  denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees back pain.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 a Life Vest wearable defibrillator for treatment of her medical condition. Findings: Two reviewers found that the superior efficacy of the wearable device at issue has been met in this patients case.  Due to a sustained ventricular arrhythmia requiring defibrillation and a dilated cardiomyopathy with low ejection fraction the wearable cardioverter defibrillator (WCD) was more likely to reduce this patients risk from sudden cardiac death (SCD).  In patients who are at high risk of SCD while undergoing a trial of optimal medical therapy, the WCD provides protection against SCD while awaiting improvement in left ventricular function, ICD implantation, or if needed, cardiac transplantation. In the largest post-marketing study of the WCD, 0.7 percent of patients prescribed a WCD for recently diagnosed non-ischemic cardiomyopathy required shocks for a ventricular tachyarrhythmia over a mean follow-up period of 57 days (Ching, et al). Although this event rate was relatively low, for selected patients with severe but potentially reversible cardiomyopathy, such as tachycardia or myocarditis, associated cardiomyopathy, the WCD may be useful for the prevention of SCD due to ventricular arrhythmias. For all these reasons, the WCD provided to the patient, was likely to be more beneficial for treatment of her medical condition than any available standard therapy.  Final Result: Two reviewers determined that the device at issue was 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 physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested a panniculectomy for the treatment of her abdominal pain secondary to hernia and ovarian surgeries. Findings:  The physician reviewer found that the submitted clinical evidence does not establish that the requested procedure is reconstructive in nature. The condition does not constitute an abnormal structure of the body because a pannus in and of itself is just a variant of a normal abdomen unless it contains a cancer or some other skin condition. The clinical records provided for review do not document the presence of any such condition. There is no documented abnormal structure directly related to the pannus caused by congenital defect, developmental abnormality, trauma, infection, tumor or disease. The patients condition is normal in that a large percentage of the population has some degree of pannus and the size of the patients pannus is not so great as to be considered abnormal. Furthermore, with regard to general concepts of medical necessity, there is no documented objective evidence of a functional impairment that has failed to respond to conservative management. The submitted photographs do not show any skin breakdown or rashes. A physical examination documented only mild intertrigo. There is no evidence that the patient has tried and failed standard treatments for this condition. Furthermore, the proposed procedure is not likely to resolve the patients reports of back pain. Therefore, the medical necessity of the proposed panniculectomy has not been established.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old male enrollee requested authorization and coverage of a GlucoWatch. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees diabetes mellitus.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old male enrollee who requested authorization and coverage of the medication Viagra for erectile dysfunction.  The health plan denied the enrollees request indicating that viagra is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication, HP Acthar Gel, 80 units twice a week. The enrollee has seronegative rheumatoid arthritis and systemic lupus erythematosus. The enrollee began treatment with prednisone and Plaquenil. Methotrexate and Enbrel were added, with partial benefit. The enrollee has trialed Humira, Cimzia and Actemra without benefit. Methotrexate was discontinued due to gastrointestinal upset. The enrollee was started on Simponi Aria intravenous infusions. She continues to take Plaquenil with significant control of her disease. Her rheumatologist is requesting HP Acthar Gel, 80 units/mL, to treat the enrollees systemic lupus erythematosus. The enrollees rheumatologist indicates corticosteroids are contraindicated in this enrollee due the severe mood disorder side effects and interactions with Lamictal. Acthar gel is composed of adrenocorticotropic hormone. This hormone works by stimulating the production of cortisol. Adrenocorticotropic hormone has not been proven as safer as or more effective than conventional corticosteroids in the medical literature or peer-reviewed journals. Adrenocorticotropic hormone has not been endorsed for the management of any autoimmune condition by the American College of Rheumatology. Adrenocorticotropic hormone is not used routinely, nor is it considered the standard of care. The medical literature indicates Acthar gel has little evidence supporting its use. Review of the record indicates the enrollee has been treated previously with prednisone and plaquenil, with no mention of any side effects with prednisone. A subsequent note indicates the enrollee cannot take prednisone, methylprednisolone, or solumedrol due to contraindications with lamictal and severe mood disorder side effects. There is no documentation in the record of side effects with the previous use of prednisone. Additionally, prednisone/corticosteroids are not contraindicated with Lamictal per prescribing information. The prescribing information for Acthar Gel notes the common adverse reactions are similar to those of corticosteroids, such as fluid retention, alteration in glucose tolerance, elevation in blood pressure, behavioral and mood changes, increased appetite and weight gain. Therefore, if corticosteroids are considered contraindicated due to severe mood disorder, then clearly the same effect could be expected with Acthar gel.                                                          Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for Optune therapy from 6/20/16 forward.  Findings:  The physician reviewer found that central nervous system tumors are classified by the World Health Organization based on their proliferative potential, morphology, and molecular genetics and are conferred grades I-IV.  Anaplastic astrocytomas and glioblastoma multiforme are high grade tumors that are best treated with resection, radiation therapy, and chemotherapy.  Chemotherapy prolongs survival, but the gains are modest.  The standard of care is to resect the glioblastoma multiforme maximally followed by treatment with temozolomide.  This patient has exhausted these options.  The U.S. Food and Drug Administration (FDA) has approved Optune, formerly known as the NovoTTF-100A device, to deliver alternating electrical fields to treat recurrent glioblastoma multiforme.  Recently, the FDA expanded the indication for Optune to include newly diagnosed glioblastoma multiforme when used along with temozolomide and radiation therapy.  There is sufficient medical evidence to demonstrate the safety of this device and it is medically justified and reasonable. Final Result: The reviewer determined that the services at issue were and 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 medical 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: Upheld

The patient is a 56-year-old man with previously diagnosed attention deficit disorder (ADD). The submitted records indicate the patient has been previously treated with Ritalin, Cylert, Celexa, and Adderall. In July 2003, it was noted by the patients provider that the patients mood, sleep, and obsessive worrying improved at a higher dose of Celexa (80 mg/day). The submitted records also indicate that as of September 2003 the patient was receiving Strattera 80 mg, Provigil 200 mg, Tegretol 200 mg, and Risperdal 0.5 mg. At that time it was noted that Provigil was helping with productivity. It was also noted the patient was afflicted with anxiety but perceived things better secondary to Strattera. The patient has requested authorization and coverage for Provigil. The Health Plan has denied the request indicating that Provigil is not medically indicated for the patients diagnosis.The submitted records do not include a definitive accounting of the patients ADD. For example, it is unclear why the patient would require Tegretol or Risperdal if he was experiencing ADD. In addition, the records appear to indicate the patient had a positive response at least in terms of mood symptoms to a higher dose of Celexa. Moreover, there was also documentation of improvement with Strattera as the patients perception of things seemed to improve after a trial of the medication. Finally, there are insufficient studies supporting the use of Provigil for bona fide ADD. Given these factors, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old male enrollee requested authorization and coverage of the medications Peg-Intron, Epogen and Neupogen. The Health Plan denied the request indicating that the medications are not medically necessary for treatment of the enrollees hepatitis C.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medications are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for pantoprazole sodium DR. The enrollee has a history of gastroesophageal reflux disease, coronary artery disease, and a myocardial infarction. He was admitted with a second myocardial infarction. He underwent a cardiac catheterization with stent placement. During admission, it was noted that he had been taking his Pravastatin and Plavix only every other day due to dark stools. While in enrollee, his medications were changed to Crestor, Plavix, and aspirin, and pantoprazole was added to his medication regimen. This enrollee was prescribed pantoprazole; however, there is no contraindication for the use of an alternative proton pump inhibitor. Records do not indicate the enrollee has tried or failed an alternative proton pump inhibitor. The use of pantoprazole is not superior to other proton pump inhibitors in this drug class. Though this medication is Food and Drug Administration-approved for the treatment of gastroesophageal reflux disease and/or gastrointestinal bleeding, it is not necessary for this enrollee to use this medication instead of other available medications. Literature shows there are no significant differences among equivalent doses of proton pump inhibitors for the treatment of non-erosive gastroesophageal reflux disease. Therefore, the choice of agent is an unlikely cause of refractory gastroesophageal reflux disease. This enrollees medical condition can be equally treated with other proton pump inhibitors.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in internal 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xeljanz. Alopecia areata is a chronic immunological disorder characterized by round or oval patches of non-scarring hair loss. Alopecia universalis is a form of alopecia areata including eyebrows, eyelashes and facial hair. Treatment focuses on the regrowth of hair. Alopecia areata can negatively affect patients self-esteem, body image, and self-confidence. Xeljanz is an oral Janus kinase (JAK) inhibitor that has been U.S. Food and Drug Administration (FDA) approved for the treatment of moderate to severe rheumatoid arthritis. Xeljanz has been also studied for treatment of psoriasis, inflammatory bowel disease, and other immunological diseases. Several recent reports in the literature provide evidence for the effectiveness of Xeljanz in the treatment of alopecia areata. Given the support in the peer-reviewed medical literature, Xeljanz twice daily is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the requested medication is 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:  One reviewer is board certified in dermatology and is actively practicing. One reviewer is board certified in dermatology and is actively practicing.  One reviewer is board certified in dermatology and is 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested surgical services on an emergent basis. The physician reviewer found that the patient presented with a well-documented clinical scenario of an infected implant that required emergency treatment. She was noted to have purulent fluid coming from her left breast, associated with an underlying prosthetic implant. The treating surgeon noted this fact with his initial evaluation and recommended a same day surgery to washout and remove the implant. His indication for surgery noted a left periprosthetic infection. The fact that the patient had been experiencing symptoms for several days does not lessen the severity of the situation. Further, while the patient did not present with evidence of fever or systemic infection, her condition could have lead to a systemic infection in the absence of immediate treatment. An article by Prince and colleagues discusses implant salvage after infection and exposure. According to the authors, The key change involves the timing of antibiotic treatment. The majority of our patients who undergo attempted salvage do so as soon as possible and preferably on the same day as their presentation. This supports the need for immediate treatment of presumed implant infection.  Based upon the submitted medical documentation, the patient had evidence of a significant infection associated with a breast implant and required immediate attention.  She was instructed that she had a significant infection and required immediate treatment. All told, a prudent layperson in the patients circumstances would have sought immediate medical attention.  Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The 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: Urgent Care
Decision: Overturned

The parent of a seven-year-old female enrollee has requested emergency services for the treatment of the enrollee's medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the parents circumstances would believe their child was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. The medical records relate that the parents reported that the patient awoke from sleep, screaming and could not be comforted/touched for one hour. The physician then had a discussion with the parents regarding a spinal tap to rule out meningitis. The patients symptoms were concerning enough that the treating physician considered a lumbar puncture; thus, it is also likely that a prudent layperson in the parents circumstances would consider such symptoms to constitute an emergency which required immediate medical attention.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a 7T magnetic resonance imaging (MRI) machine, which would be used both before and during an endonasal endoscopic transsphenoidal pituitary tumor surgery to remove microadenoma. Microadenomas in Cushings disease are difficult to visualize preoperatively and challenging to identify intraoperatively. Adrenocorticotropin-secreting pituitary tumor represents approximately 10% of pituitary adenomas, which at the time of diagnosis, were microadenomas. Transsphenoidal surgery is the first-line treatment of Cushings disease and accurate localization of the tumor within the gland is essential for selectively removing the lesion and preserving normal pituitary function. MRI is the best imaging modality for the detection of pituitary tumors. However, adrenocorticotropin-secreting pituitary microadenomas are not identified in up to 50% of patients because of their size, location, and enhancing characteristics. One recent study found that in this clinical setting, lesions were detected more accurately with 7.0 T MRI as compared to 1.5 T MRI. Given this support, the requested 7T MRI machine, which would be used both before and during an endonasal endoscopic transsphenoidal pituitary tumor surgery to remove microadenoma, is medically necessary for 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 neurological 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 parents of a six-year-old male have requested a speech evaluation and speech therapy for treatment of speech disorder.  Findings:  The physician reviewer found that recent studies from peer reviewed journals show no association, to a very small negative association, between OME and the childs later speech and language development. These studies concluded that attempts at early detection of OME in the asymmetric child to prevent delayed language development were not warranted. The studies also found that any association between early OME and language development found at the pre-school age, was no longer present by school age. Based on the inconsistent recommendations, the presence of normal hearing and the peer-reviewed evidence, the services at issue were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old female enrollee requested authorization and coverage of individual psychotherapy two times a week, day treatment three times a week, and continued psychiatric care for the treatment of an autistic disorder.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old male enrollee has requested a CPAP machine for treatment of his excessive daytime somnolence. Findings:  The physician reviewer found that based on subjective complaints and polysomnographic findings, this patient may be suffering from upper airway resistance syndrome (UARS). UARS is a condition in which patients complain about excessive daytime sleepiness and they may snore and wake frequently during the night. UARS patients may not have the breathing abnormalities that characterize OSA and they may not show a reduction in oxygen saturation as seen in patients with OSA according to Exar and Collop. Treatment of UARS includes CPAP, surgery, and oral appliances. In the case of this patient, the CPAP device should be considered medically indicated to improve his daytime somnolence and snoring.