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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for fertility preservation (ovarian stimulation, oocyte retrieval, oocyte fertilization and storage of oocytes and/or embryos) and medications prescribed in relation to and in preparation for fertility preservation services. Egg retrieval and egg and/or embryo freezing (cryopreservation) is now a recognized option for patients who have cancer who are undergoing treatment that can render them infertile. This option allows these patients to have children in the future. These patients are not infertile when undergoing the procedure, as the goal is to protect their gametes from the effect of the chemotherapy. This treatment is supported by the American Society of Reproductive Medicine. When chemotherapy is anticipated to damage or destroy the patients eggs, fertility preservation is medically necessary. Researchers noted that discussion of fertility preservation and appropriate referral for treatment of reproductive age (and younger) cancer patients should be a routine part of cancer care, noting that sperm and embryo cryopreservation and oocyte cryopreservation are considered standard practice. In this patients case, the services at issue and medications at issue were medically indicated and a part of their cancer care. Therefore, fertility preservation (ovarian stimulation, oocyte retrieval, oocyte fertilization and storage of oocytes and/or embryos) and medications prescribed in relation to and in preparation for fertility preservation services were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue and medications at issue were 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 obstetrics and gynecology 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 26-year-old female enrollee has requested Apriso 0.375G capsule SR 24H 4 QD for treatment of her ulcerative colitis. Findings:  The physician reviewer found that there is a lack of evidence indicating that the ulcerative colitis is severe, as biopsy findings did not show active disease, except in the distal rectum.  Disease in the distal rectum is not controlled by Apriso. Moreover, there is a lack of data supporting the use of Apriso in cases of flares on mesalamine.  All told, the medical documentation demonstrates that the only segment with active inflammation is the distal rectum, and Apriso has not been shown to control flares in the distal rectum where mesalamine has failed. Apriso is medically indicated in cases involving maintaining response to mesalamine, and not in treating mesalamine failures.  Thus, the requested Apriso 0.375G capsule SR 24H 4QD is not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for the lab tests (CPT code 83520 and 8352059). Monoclonal gammopathy is a potential reversible cause for neuropathy. The appropriate testing by serum protein electrophoresis is considered within the standard of care when evaluating a patient for neuropathy without apparent etiology. A medical literature reviewed the standard battery of tests for neuropathy to help identify reversible causes for neuropathy. The authors concluded that serum protein electrophoresis is recommended for evaluation of neuropathy in this clinical setting. As this patient presented with neuropathy of unknown etiology, the lab tests (CPT code 83520 and 8352059) were likely to be more beneficial for evaluation of the patients condition than any available standard therapy.One reviewer found that the lab tests (CPT code 83520 and 8352059) were not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were 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:  One reviewer is board certified in neurology with subspecialty certification in pain management and is actively practicing. One Reviewer is board certified in neurology and is actively practicing.  One Reviewer is board certified in neurology with subspecialty certification in neuromuscular medicine 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: Medical Necessity
Decision: Overturned

A 23-year-old male enrollee has requested for continued follow-up by an endocrinologist for treatment of his diabetes. Findings:  The physician reviewer found that this patient has had persistent uncontrolled hyperglycemia as well as frequent episodes of hypoglycemia as noted in his glucose sensor reports. Continued follow-up with an endocrinologist is medically necessary to help manage his disease and prevent both short-term complications of hypoglycemia, as well as long-term complications of hyperglycemia.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested for Harvoni for 12 weeks for treatment of the enrollees hepatitis C virus.  Findings:  Three physician reviewers found that the patient presents with HCV genotype 3 status post liver transplantation. There is a lack of support in the peer-reviewed literature demonstrating the efficacy of Harvoni in the treatment of HCV genotype 3 patients. There is no recommendation from American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines to treat genotype 3 patients with Harvoni in sofosbuvir-experienced patients. Moreover, the patient has very early to no fibrosis after 13 years liver transplantation. In sum, due to the paucity of data demonstrating support for Harvoni in genotype 3 patients, Harvoni is not medically necessary in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 33-year-old female enrollee has requested intensity modulated radiation therapy (IMRT) for treatment of her breast cancer.  Findings:  Two physician reviewers found that IMRT is the technology used for delivering highly conformal external beam irradiation to solid tumors.  This technique results in a more conformal target coverage and normal tissue sparing as compared to three-dimensional conformal radiation therapy.  This is particularly useful for obtaining highly conformal dose distributions needed to irradiate complex targets positioned near or immediately adjacent to sensitive normal tissues.   IMRT requires an inverse plan with dose constraints for normal surrounding anatomy.In a letter from the date in question, the provider indicated that this patient received IMRT to give homogenous dose to the right breast to decrease skin toxicity, and reduce scatter dose to contralateral breast, which would reduce the likelihood of second cancer.  The provider further stated that multiple studies have shown that IMRT reduces scatter dose to contralateral breast and other parts of body.  In this patients case, the superior efficacy of IMRT has not been established.  In reviewing the dose-volume histogram (DVH) sheet, comparing IMRT to the three-dimensional conformal plan, there is no significant advantage of the IMRT plan. Furthermore, the papers that were submitted to support the use of IMRT do not pertain to this patients case.  All told, in this patients case, IMRT was not likely to have been more effective than other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old male enrollee requested authorization and coverage of an MRI of the brain to screen for cysticercosis.  The health plan denied the enrollees request indicating that the requested MRI is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested MRI is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The father of an 11-month-old female enrollee requested authorization and coverage of a portable nebulizer. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees respiratory problems.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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS).Findings:  Two of the three physician reviewers found the records documented bipolar I disorder. Following the Health Plans denial, the diagnosis was changed to major depressive disorder. On 2/05/18, the records noted that the patient was currently taking lamotrigine, quetiapine, and duloxetine for the treatment of his depression. Both lamotrigine and quetiapine are U.S. Food and Drug Administration (FDA) approved for the treatment of bipolar disorder. Lamotrigine and quetiapine are not FDA approved for the treatment of unipolar major depressive disorder. Thus, the records indicate that the patient is psychopharmacologically being treated for bipolar disorder, and documentation states that the patient was previously hospitalized in a psychiatric unit due to manic episodes. The patients manic episode which led to his hospitalization was questioned due to co-occurring substance use at the time of the hospitalization. TMS treatment is not FDA approved for the treatment of bipolar disorder. At this time, there is lack of evidence to support the use of TMS for the treatment of bipolar depression. Therefore, TMS is not likely to be of greater benefit than other available treatment options. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in psychiatry 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:   An enrollee has requested monitored anesthesia care during a colonoscopy procedure for evaluation of his medical condition.  Findings:  The physician reviewer found that for this patient, there is no documentation of clinical findings that would support the need for monitored anesthesia. The patient has a low (ASA) preoperative physical status classification score, which indicates a healthy individual.  Intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist are well supported in both clinical practice and in the research. Therefore, given a low preoperative physical status classification score,  monitored anesthesia care was not medically necessary during the patients colonoscopy procedure. The Health Plans denial should be upheld.  Final Result: The reviewer determined that the anesthesia services at issue were not medically necessary during the patients colonoscopy procedure. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in anesthesiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 46-year-old male enrollee has requested use of a real time cardiac monitoring device for an evaluation of his sinus tachycardia. Findings:  Two physician reviewers found that this patient had chest pain, sinus tachycardia, and shortness of breath, which have numerous possible diagnoses. There is no clinical history to suggest syncope, which would be an appropriate indication for real time cardiac monitoring. Review of the submitted clinical evidence demonstrates that the disputed service was not likely to be of greater diagnostic value or more appropriate than available standard care including echocardiography, metabolic testing and stress testing.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted records do not support the medical necessity of the services at issue.  The record does not demonstrate that 24-hour supervision was clinically indicated. The patient could have been treated at a less restrictive level of care such as intensive outpatient program (IOP) treatment. As noted by colleagues, Multiple randomized trials and naturalistic analyses that compared IOPs (Intensive Outpatient Programs) with inpatient or residential care found comparable outcomes.  Moreover, in their review colleagues found that Results for the effectiveness of residential treatment compared with other types of treatment for substance use disorders were mixed. Findings suggested either an improvement or no difference in treatment outcomes. It was noted that the patient had a strong probability of not relapsing. She had strong family support system. She had a sponsor. She was not a danger to self. This patient could have been treated at a lower level of care such as at an IOP. In sum, the residential treatment services provided were not medically necessary for the treatment of this patient. 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 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 28-year-old female enrollee has requested for Prestige ST artificial cervical disc surgery for treatment of her neck and shoulder pain and arm symptoms.   Findings:  The physician reviewer found that cervical discectomy and fusion, is considered the standard procedure in this country for symptomatic degenerative disc disease within the cervical spine.  Although artificial disc procedures seem promising, there is no long-term data to establish the clinical safety and efficacy of this procedure over the standard one at this time.  In the absence of long-term data, there is no evidence to support the requested procedure as medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary: This is a patient with long-standing psoriatic arthritis with recurrent polyarthralgias (several joints with pain), rash, psoriatic lesions on the forehead, joint tenderness, swelling, synovitis, fatigue, disrupted sleep and pain 5/10 on a 1-10 scale. The patient also has type II diabetes, Hashimotos thyroiditis (underactive thyroid gland) and hypogammaglobulinemia (lower globulin protein level impairing the immune system). The patient is on methotrexate, Otezla and Humira and had been on prednisone up until recently. Although Acthar Gel is Federal Drug Administration (FDA) approved for adjunctive therapy for short-term administration for an acute episode or exacerbation in psoriatic arthritis, the current literature with respect to the long-term safety and efficacy (ability to produce a desired or intended result) is not well established. Acthar Gel was designed as a bridge therapy and not a maintenance therapy for inflammatory conditions. Researchers have documented multiple discontinuations of Acthar due to typical steroid side-effects such as weight gain, hyperglycemia and hypertension.  If this patient requires maintenance therapy with a biological agent other than those that may have failed in the past, there are available treatment options for psoriatic arthritis. Acthar has not been demonstrated to be superior to steroids or other biological agents in terms of efficacy or safety. Due to corticotrophin properties, Acthar gel is associated with the same adverse effects expected with any steroids. Treatment options include sulfasalazine or leflunomide (instead of methotrexate), other anti-tumor necrosis factor agents and other special inhibitor agents. These choices have demonstrated long-term anti-inflammatory and disease remittive properties. There is no evidence Acthar achieves disease remission.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 authorization and coverage for right hip arthroplasty. The submitted documentation supports the medical necessity of the requested procedure. Official Disability Guidelines (ODG), nationally recognized evidence based medical guidelines, recommend total hip arthroplasty when all reasonable conservative measures have been exhausted and other reasonable surgical options have been seriously considered or implemented. A study concluded that six months after total joint replacement (TJR), severely or morbidly obese patients reported excellent pain relief and substantial functional gain that was similar to the findings in other patients. While obesity is associated with a greater risk of early complications, obesity in itself should not be a deterrent to undergoing TJR to relieve symptoms. In this case, a patient presents with a history of chronic right hip/groin pain and associated functional mobility limitations. Clinical exam findings have been consistent with imaging evidence of severe right hip osteoarthritis. Detailed evidence of reasonable and/or comprehensive non-operative treatment, including activity modification, medications, corticosteroid injections, physical therapy, acupuncture, weight loss, and chiropractic, and failure has been submitted. This patient has a markedly elevated body mass index above 50 and has been unable to lose more than 50 pounds. There is evidence of significant weight loss attempts including weight loss programs and bariatric surgery. There is evidence of significant psychological barriers to additional weight loss. She is requesting authorization to proceed with total hip replacement with an out-of-network orthopedic specialist who has discussed the increased risk factors and is willing to proceed with total hip replacement. There is evidence based medical literature support to proceed with total hip replacement for pain relief and functional improvement in the setting of morbid obesity and as a relative exception to guidelines. Therefore, the requested right total hip arthroplasty is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested procedure 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 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: Experimental/Investigational
Decision: Upheld

A 35-year-old female enrollee has requested an MRI of the left breast for an evaluation of her left breast lump. Findings:  Two physician reviewers found that the American Cancer Society has developed guidelines for the use of MRI in breast cancer diagnosis and monitoring. It is used for screening in women at very high risk for breast cancer. It is also used for known breast cancer patients for determining the extent of disease or monitoring therapy. Breast MRI is also used for suspicious clinical findings or imaging results that remain indeterminate after complete mammography and sonography as well as clinical examination. This patient has a mass clinically and on mammogram. The decision for tissue excision should be based on these clinical and diagnostic impressions. MRI is not indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Wakix 17.8 mg tablets. The documentation provided for review supports a diagnosis of idiopathic hypersomnia. The patients multiple sleep latency test (MSLT) demonstrated sleep latency of eight minutes but no sleep onset rapid eye movement (SOREM), which is consistent with idiopathic hypersomnia. The records do not demonstrate a diagnosis of narcolepsy. Moreover, the records do not specify the patients previous treatment doses, if higher doses were attempted, and the patients response. Wakix is a new medication U.S. Food and Drug Administration (FDA) approved for the treatment of patients with narcolepsy. Studies are promising on the effects of Wakix on patients with idiopathic hypersomnia. However, the FDA has not approved Wakix for the treatment of excessive daytime sleepiness for idiopathic hypersomnia and there is limited medical literature to support its use in this clinical setting. All told, the requested Wakix 17.8 mg tablets are 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 internal medicine with subspecialty certification in sleep 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.