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 Ubrelvy 100 mg. The American Headache Society (AHS) notes that in individual pharmacological therapies for acute migraine treatment, non-steroidal anti-inflammatory drugs (NSAIDS) and triptans are effective for the treatment of acute migraine attacks. Mullin and colleagues report that calcitonin gene-related peptide (CGRP) receptor antagonists are a newer drug class with treatment benefits in migraine therapy. The U.S. Food and Drug Administration (FDA) describes Ubrelvy (generic name ubrogepant) as a CGRP receptor antagonist indicated for the acute treatment of migraine with or without aura in adults, with recommended doses of 50 mg or 100 mg taken orally, as needed. In a randomized trial to evaluate the efficacy, safety, and side-effect profile of ubrogepant, Dodick and colleagues concluded that a higher percentage of participants who received ubrogepant than of those who received placebo had freedom from pain and absence of the most bothersome symptom at two hours after the dose. While the AHS guidelines have not yet been updated to include recommendations on CGRP therapies, Pringsheim and colleagues note that when the initial treatment for an acute migraine does not provide meaningful and sustained benefits, a treatment from a different medication class is typically chosen. In this case, the patient has a history of migraines that have not responded to multiple oral abortive medications. Given that current medical literature supports the use of Ubrelvy, an alternative treatment in a different medication class, for the treatment of acute migraines in adults, the requested medication is medically indicated. Therefore, Ubrelvy 100 mg is medically necessary for the 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 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

A 43-year-old female enrollee has requested for Celebrex 200mg for treatment of her osteoarthritis. Findings:  The physician reviewer found that this patient has failed two NSAIDs, and it is medically reasonable to require that the patient try at least two other NSAIDs prior to coverage for Celebrex.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for removal of bilateral breast implants with bilateral mastopexy (breast lift) for treatment of the enrollee who has had a history of left breast pain. Findings:  The physician reviewer found that based on the medical documentation for this review, the patient appears to have a possible complication from a cosmetic procedure, in which her volume of augmentation was excessive. She has undergone physical therapy, but appears to continue to complain of pain. However, the plastic surgery documentation does not support that her enlarged breast size is the source of the pain, but is more likely due to her history of the motor vehicle accident. Moreover, the plan by the plastic surgeon is more consistent with cosmetic intervention, as the plan was to remove the implants and then perform a mastopexy. Thus, a well-defined functional impairment that would likely be resolved with implant removal and mastopexy has not been adequately supported in this patients case. There are times when a mastopexy or implant removal may be considered reconstructive surgery, namely following postmastectomy reconstruction and congenital breast deformities. However, there is no documentation to support this or that the patient had an original congenital breast deformity. There is insufficient documentation that her preoperative condition was significantly abnormal given her previous cosmetic intervention. Although the patient has pain, the medical documentation from the provider does not support that this is likely due from the enlarged breasts. As such, the medical records do not support that the mastopexy and implant removal are being performed for treatment regarding functional concerns. Instead, this request is more consistent with aesthetic treatment following complicated cosmetic surgery. In addition, the plan for mastopexy appears supportive or aesthetic intervention. For these reasons, removal of bilateral breast implants with bilateral mastopexy (breast lift) is not medically necessary and not reconstructive in nature.Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Praluent Pen 75 mg for treatment of the enrollees hyperlipidemia. Findings:  The physician reviewer found that the physician reviewer found that the patient has documented obstructive coronary disease, severely elevated LDL cholesterol and intolerance to both multiple statin medications and Vytorin. In this circumstance, treatment with a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor is medically appropriate. Praluent is a PCSK9 inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient fits the latter criteria. In this setting, PCSK9 inhibitors have been shown to be safe and effective, with improved cardiac outcomes in prospective randomized trials. Therefore, Praluent Pen 75 mg is medically necessary for the 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 internal medicine with sub-specialty certification in cardiovascular 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

The parents of a 16-year-old female enrollee requested authorization and coverage of continued acute inpatient treatment. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.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.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old female enrollee has requested genioglossus advancement and hyoid suspension surgery for the treatment of her obstructive sleep apnea. Findings:  The physician reviewer found that this patient did have a more recent polysomnography that reveals the presence of severe OSA with an AHI of greater than 90, that she has tried CPAP and failed, that she has endoscopic evidence of retro-palatal/hypopharyngeal obstruction, and that she has failed UPPP, she does appear to meet the Health Plans criteria for genioglossus advancement and hyoid suspension. These criteria are consistent with the standard of care in this setting.
Appeal type: Medical Necessity
Decision: Upheld

A sixty-two year-old male who underwent a right shoulder rotator cuff repair, acromioplasty, resection of the coracoacromial ligament and partial bursectomy is requesting reimbursement for the rental cost of electronic-controlled thermal therapy device.Reviewers Findings:  The reviewing physician found that date there is no evidence in peer reviewed literature establishing the clinical benefit of an electronic-controlled thermal therapy device over the application of an ice bag and compression with an elastic bandage.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eight-year-old male enrollee has requested  speech therapy for treatment of his autism and verbal apraxia. Findings:  The physician reviewer found that patients with autism spectrum disorders (ASDs) have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate.  Most children with ASDs can develop useful speech and chronologic age, lack of typical prerequisite sills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services (Myers, et al.).  A controlled study comparing autistic children who did and did not receive speech therapy demonstrated that children who did receive therapy had far greater communication skills than children who did not receive speech therapy (Turner, et al.). The report of the Speech and Language Association states that all autistic children can benefit from speech therapy and that age, either early or late in life, is not a barrier to speech therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old male enrollee requested sinus endoscopy with balloon dilation (CPT 31295) for treatment of the enrollees medical condition.  Findings:  Three physician reviewers found that in this patients case, the services at issue were not likely to have been more effective than other available options.  Per the clinical records, this patient had nasal congestion and blockage.  The records do not support the diagnosis of chronic sinusitis.  In this clinical setting, sinus surgery was not indicated.  The CT scan does not demonstrate the need for sinus surgery in this patients case.  Thus, sinus endoscopy with balloon dilation was not likely to have been superior over other available treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the services provided. This patient has a formidable formal thought disorder with co-occurring personality disorder and substance use disorder. Indeed, his longitudinal history and symptom inventory, particularly the well-entrenched delusional thought system, is consistent with severe impairment and grave disability. The patients illness burden has impacted all functional domains. His fixed false beliefs generated prominent intrapsychic distress and impulsive moves to escape perceived persecution while his errant behaviors placed both himself at others at risk. The patient demonstrated delusional beliefs and his symptoms included decreased interest, poor concentration, and insomnia. On examination, he had poverty of speech, blunted and restricted affect and poor insight. He was anxious, delusional, paranoid and perseverating. Given the patients lack of response to prior treatment attempts and his continued illness burden, discharge would have been premature. At that time, treatment in a less intensive setting would have been unsafe and inadequate, and more than likely would have resulted in prompt readmission to an acute psychiatric unit. Thereafter, the patient engaged in treatment activities and made some progress in terms of insight and behaviors. However, he remained symptomatic. Per the psychiatry notes from January to late February, the patient still felt that he was being followed. He needed pressing from the staff to participate in some areas of his treatment, such as Alcoholics Anonymous. Based on the available documentation, the services and setting were reasonably expected to improve the patients condition and prevent a more serious episode of illness and need for inpatient care. Thus, the residential services were medically necessary for treatment of the patients medical condition. Moreover, a transitional living environment represented the next reasonable step in the treatment algorithm of this case and the placement was an appropriate disposition with a duration consistent with community norms. Thus, the transitional housing services were medically necessary. Accordingly, the services provided at Spring Lake Ranch were medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the services 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 psychiatry with sub-specialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for armodafinil (Nuvigil) for treatment of the enrollees idiopathic hypersomnia. Findings:  The physician reviewer found that current diagnostic criteria for idiopathic hypersomnia require an exclusion of other causes of daytime sleepiness and objective findings on testing to establish the diagnosis. In this case, the patient does not meet the diagnostic criteria based on the information provided for review. The patient did not undergo a multiple sleep latency test (MSLT) and the PSG suggested possible insufficient sleep time. In addition, the patient has another potential cause of sleepiness which is post-stroke fatigue. Post-stroke fatigue is a common finding in patients who have sustained a stroke. Studies have been taken to evaluate the use of pharmacotherapy in post-stroke fatigue. However, there is no conclusive evidence supporting the efficacy of pharmacotherapy. Currently, further study of pharmacotherapy for this condition is needed. Nuvigil has not been studied directly for post-stroke fatigue. Nuvigil is the R-enantiomer of modafinil which is a racemic mixture and a recent phase 3 study on modafinil failed to show any benefit when compared to placebo. In this case, the diagnosis of idiopathic hypersomnia is not supported by the records and there is a lack of published evidence of efficacy of pharmacotherapy in post-stroke fatigue. All told, the requested armodafinil (Nuvigil) is not medically necessary for treatment of this patients medical condition. 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 neurology with sub-specialty 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.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 1-year, 10-month-old female enrollee has requested coverage for right cornea replacement procedure (corneal transplant) for treatment of the enrollees congenital corneal opacity.  Findings:  The physician reviewer found that pediatric corneal transplantation, especially infant corneal transplantation, is particularly difficult due to relatively high complication rates and challenges in aftercare. The literature addressing corneal transplantation in infants with Peters anomaly suggests that corneal transplantation is usually performed between 3 to 6 months of age to avoid amblyopia.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for a capsule endoscopy (PillCam UGI System). A study found that capsule endoscopy (CE) was recommended for patients with suspected, known, or relapsed Crohns disease when ileocolonoscopy and imaging studies were negative if it was imperative to know whether active Crohns disease was present in the small bowel. It was not recommended in patients with chronic abdominal pain or diarrhea, in whom there was no evidence of abnormal biomarkers typically associated with Crohns disease. CE was recommended to assess patients with celiac disease who have unexplained symptoms despite appropriate treatment, but not to make the diagnosis. Colon capsule endoscopy should not be substituted routinely for colonoscopy. In this case, the patient reported GERD symptoms and a globus sensation. The patient requested a capsule endoscopy; however, his treating gastroenterologists reported it would be of low diagnostic yield. The medical evidence does not support the requested service in this clinical setting. Therefore, a capsule endoscopy (PillCam UGI System) is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 46-year-old female with a history of biopsy proven, Grade II, invasive ductal carcinoma of the left breast. Further treatment details are not provided. The patient presented to her provider in May 2006 complaining of a new nodule medial to the site of the previous left breast biopsy. Her provider noted that a mammogram and ultrasound were unremarkable, but also noted a need to determine whether or not these changes represented recurrent breast cancer. Accordingly, he requested authorization for a  PET scan. His request was denied by the Health Plan based upon a determination that the diagnostic procedure was not medically necessary.The patient has a history of breast cancer and now presents with left costosternal changes in the area of the previous left breast biopsy.  A PET scan to rule out a recurrence of her cancer appears to be consistent with the policy of the Health Plan. It is most certainly consistent with the current standard of care in Oncology and Nuclear Medicine practice. Therefore,  I have determined the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa (sofosbuvir/velpatasvir 400 mg  100) mg for 12 weeks for treatment of her hepatitis C virus. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions, regardless of fibrosis stage. Per guidelines, Epclusa for 12 weeks is recommended as first-line therapy for treatment-naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate (98%) with this regimen (Foster, et al). The guidelines no longer recommend Sovaldi with ribavirin as first-line therapy for genotype 3 hepatitis C. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Orthovisc/hyaluronic injections of both knees and prospective authorization and coverage for Orthovisc/hyaluronic injections of both knees every six months. Evidence-based peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and has been shown to be more effective than corticosteroid injections. In this case, the patient has been diagnosed with osteoarthritis of both knees. She presented with progressive bilateral knee pain with associated crepitus, grinding, and limited motion. Activities of daily living had been limited. Clinical examination findings were consistent with reported bilateral knee osteoarthritis. Conservative treatment failure has been documented to include corticosteroid injections, nonsteroidal anti-inflammatory drugs, ice, and exercise. The Orthovisc injections performed were medically necessary for the treatment of her medical condition. However, the medical necessity of future Orthovisc injections cannot be established at the time. Current evidence-based literature would support future Orthovisc injections for both knees if there is documented significant improvement in symptoms for six months or more, and symptoms recur. In sum, prior Orthovisc/hyaluronic injections of both knees were medically necessary for the treatment of this patient. However, the medical necessity of future Orthovisc/hyaluronic injections of both knees every six months has not been demonstrated.Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.