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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with hypertension, dyslipidemia, and atherosclerotic heart disease. The records noted a history of percutaneous coronary intervention. The patient was noted to have experienced left-sided chest tightness associated with weakness and shortness of breath in 2006. The patient subsequently underwent cardiac stent placement. The patient was noted to have undergone a second cardiac stenting procedure. A myocardial perfusion study revealed normal left ventricular perfusion. The patients blood pressure was noted to be 146/90. The provider discontinued Azor and prescribed Edarbyclor and amlodipine. The patient denied chest pain, shortness of breath, and palpitations. The patients blood pressure was noted to be 140/100. Samples of Edarbyclor were provided to the patient. The patient has requested authorization and coverage for Edarbyclor 40 mg-12.5 mg tablet daily. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Edarbyclor 40 mg-12.5 mg tablet daily is medically necessary for the treatment of the patients medical condition. James and colleagues reported, There is strong evidence to support treating hypertensive persons aged 60 years or older to a blood pressure goal of less than 150/90 mm Hg and hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90 mm Hg. Edarbyclor is indicated for the treatment of hypertension refractory to single drug therapy. In this case, the patient requires blood pressure control for longstanding hypertension in the setting of known ischemic heart disease. His blood pressure control was not at goal on Azor (amlodipine/olmesartan) therapy, and he had been switched to Edarbyclor (azilsartan/chlorthalidone) along with continued amlodipine for improved management. The patients blood pressure was noted to be 140/100. The medical evidence supports the requested medication in this clinical setting. Therefore, Edarbyclor 40 mg-12.5 mg tablet daily is medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lidoderm patches. The U.S. Food and Drug Administration (FDA) has approved Lidoderm patches for the treatment of post-herpetic neuralgia. McColgan and colleagues report that there is a lack of evidence to support the use of Lidoderm patches for musculoskeletal pain. Santana and colleagues evaluated the medical evidence supporting the use of Lidoderm patches for chronic low back pain. The authors evaluated seven studies and concluded that they found no randomized controlled trials with substantial evidence to support the use of 5% lidocaine patch in chronic low back pain. In this case, the patient has a known diagnosis of traumatic brain injury and unspecified injuries to the lower back and neck. Her records do not show any history of post-herpetic neuralgia or any complaints related to this condition. The records show that the patient has been using the Lidoderm patches on her back for non-specific musculoskeletal back pain. Based on the FDA approval and current medical literature, the requested Lidoderm patches 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 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: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee has requested inpatient treatment for treatment of his substance use disorder.  Findings:  The physician reviewer found that from a review of the available records, it appears that the patient, although challenged to stay abstinent from prescription drugs and alcohol, could have accessed and benefited from intensive rehabilitation services for his addictions on an outpatient basis. This patients previous attempts at detoxification and rehabilitation were greater than two years prior to this entry to care. While the patient reported work-related challenges related to his substance use disorder, no description of legal, family, or acute medical concerns necessitating an inpatient level of care were presented. Moreover, no withdrawal symptoms were noted in the records provided for review. Consistent with the references cited above, this patients substance use disorder could have adequately been managed in an outpatient program or chemical dependency partial hospitalization program (PHP). The PHP would offer this patient ongoing therapeutic intensity and structure for his continued recovery. The PHP also allows patients to receive intensive treatment during the day and practice recovery skills while living in a supportive structured environment. Less-restrictive settings promote recovery in a natural and least restrictive a setting as possible. As such, inpatient rehabilitation services were not medically necessary for care for this patient during the dates of care at issue as he could have been safely and adequately treated on an outpatient or PHP basis.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old male enrollee has requested multiple repeat series of Supartz injections for treatment of his osteoarthritis in the left knee.  Findings:  Two physician reviewers found that while there is a specific reference to osteoarthritis of the knee with varus deformity and an abnormal gait, there is no documentation of either routine x-ray examination of the left knee or standing weight bearing AP films of both knees. Given the patients age it is appropriate to consider temporizing treatment to delay total joint replacement. Total joint replacement has its own intrinsic risks including the cumulative effects of wear debris from the implanted device. While it may not be appropriate for this specific patient, some consideration for extra-articular procedures such as opening wedge osteotomy to correct the knee varus at the proximal tibia may be indicated to help delay total joint replacement should it become necessary. Further, the issue of the efficacy of repeated hyaluronan injections has not been established in the peer reviewed medical literature. In a study published by Jorgensen and colleagues, the researchers conducted a double blind a placebo controlled administration of intra-articular hyaluronate as compared to physiological saline. Overall, no efficacy was demonstrated in patients studied at 3, 6, 7 and 12 months after injection. Moreover, Evanich and colleagues concluded that patients with advanced degenerative osteoarthritis are not likely to benefit from repeated hyaluronan injections. If this patient has advanced degenerative osteoarthritis then it is unlikely that there will be any benefit from an additional series of hyaluronic acid. For these reasons, it is not in this patients best interest to have additional hyaluronan injections with Supartz.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male has requested Levitra or Viagra for treatment of his erectile dysfunction.  Findings:  The physician reviewer found that this patients records do not support the medical necessity of the requested Levitra or Viagra. Specifically, the records do not document a medical condition that accounts for the patients erectile dysfunction. Currently recognized medical conditions including hypertension, diabetes, atherosclerosis, prostate or bladder cancer, spinal cord surgery, multiple sclerosis, and certain medications can cause erectile dysfunction. However, this patient does not have any concurrent medical disorders which are commonly recognized as causative of erectile dysfunction. Therefore, the requested Levitra or Viagra are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 23-month-old male enrollee has requested coverage for occupational therapy for treatment of the enrollees developmental delays. Findings:  The physician reviewer found that global developmental delay is defined as a significant delay in two or more of the following developmental domains: gross/fine motor, speech and language, cognitive, social/personal, and activities of daily living. A diagnosis of global developmental delay involves a profile that is associated with age-specific deficits in adaptive and learning skills. These deficits are evident in comparison with the skills obtained by same-aged peers (Shevell, et al.).
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Genomind Genecept assay. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.Findings:  There is a lack of support for genetic testing as a first line approach in this clinical setting.  The Genomind Genecept assay is a pharmacogenomic test, which looks at the relationship between genetic factors and how medications are metabolized. This may provide information about whether a particular medication is tolerated by an individual; however, it does not indicate whether the medication will be effective. A review of the medical literature revealed very few clinical studies demonstrating the clinical utility of this type of testing (Walden, et al; Spina and de Leon). A review by Singh and colleagues concluded that the current evidence for pharmacogenomic testing does not provide support for its routine use. A review by Carlson and colleagues noted that testing for specific drug metabolizing enzymes in patients, especially those with treatment resistant conditions or serious adverse side effects, may be helpful; however, more studies are needed. Rahman and colleagues, in their review noted that pharmacogenetic testing does not yet have sufficient data from randomized controlled trials to alter established evidence based treatment guidelines. Accordingly, based on current medical literature, the Genomind Genecept assay was not likely to have been more beneficial for evaluating this patients medical condition than any available standard therapy.   Final Result: All three reviewers have determined the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in psychiatry with expertise in child and adolescent psychiatry and is actively practicing. Two reviewers are board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry 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: Upheld

The parent of a 17-year-old male enrollee has requested for residential treatment center level of care for treatment of the enrollees major depressive disorder, recurrent, severe, without psychotic features. Findings:  The physician reviewer found that this patient appeared to change with an oncoming stressor, sometimes to the point of decompensation.  Thus, this presented a challenge to the treatment team. However, the medical records do not demonstrate that this patient required the restrictive environment of the residential treatment center.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The patient has requested coverage for Repatha SureClick autoinjector. Findings: The physician reviewer found that the patient had a history of coronary vascular risk factors including coronary artery disease, status post stent, diabetes mellitus, hypertension and elevated cholesterol.  The diagnoses included sclerotic heart disease of native coronary artery with a known history of coronary artery disease, status post prior percutaneous transluminal coronary angioplasty (PTCA). The American College of Cardiology and the American Heart Association support consideration of the addition of a non-statin cholesterol lowering therapy, such as Repatha in high risk patients, those with diabetes, those between the age of 40-75 who have a less than anticipated response to statins or are statin intolerant. Medications, such as Repatha, have demonstrated a decrease LDL levels. This patient had tried first line treatments and had significant risk factors that support the use of Repatha.Final Result: The reviewer determined that the service at issue was medically necessary for treatment of the patients condition. Therefore, the health plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in Cardiovascular Disease and Interventional Cardiology and is actively practicing.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS). Findings:  The physician reviewer found that the majority of the evidence based literature on TMS is dedicated towards the treatment of major depressive disorder. The evidence for TMS in the treatment bipolar I disorder is minimal. The literature also indicates that there have been instances where treatment with TMS, in individuals with bipolar I disorder, has induced dangerous symptoms of mania.  Overall, the evidence base does not support the use of TMS for bipolar I disorder. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa (sofosbuvir-velpatasvir tablets 400-100 mg) for treatment of the enrollees hepatitis C.  Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions.  This applies regardless of fibrosis stage.  The guidelines support treatment in patients with cryoglobulinemia, stating that adverse extrahepatic effects such as renal impairment and vasculitis can result from cryoglobulinemia.  Per the guidelines, Epclusa is recommended as first-line for treatment-naive genotype 2 patients. Delay in treatment may result in decreased survival.  For these reasons, Epclusa (sofosbuvir-velpatasvir tablets 400-100 mg) is medically indicated 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 overturnedCredentials/Qualifications: Physician 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: The patient has requested authorization and coverage for bilateral lumbar facet joint injections at L3-4, L4-5 and L5-S1. Researchers evaluated the effectiveness of lumbar medial branch blocks and facet joint injections in patients with chronic low back pain. The authors found that the proportions of positive blocks were higher in the intraarticular (54%) and medial branch (55%) groups than in the placebo group. The authors concluded that their results suggest that facet blocks might provide prognostic value before radiofrequency ablation. Researchers noted that, the evidence for lumbar facet joint nerve blocks using local anesthetics with or without steroid for managing chronic low back pain of facet joint origin is fair to good for short- and long-term improvement. The authors endorsed the use of medial branch blocks for diagnostic purposes, to help establish whether a patient may benefit from future radiofrequency ablation. In this case, the patient has chronic low back pain with degenerative disc disease on MRI affecting L3 through S1. Per the records, physical examination was notable for positive facet joint loading and negative for straight leg testing. There is no evidence of motor weakness or sensory abnormalities. The provider charted that the patient has tried and failed six weeks of physical therapy over six months as well as medication management including non-steroidal anti-inflammatory drug (NSAID) and opioid therapy. She has tried lumbar facet injection at these levels before at these levels and reported more than seven months of pain relief. The current peer-reviewed medical literature supports the use of diagnostic facet joint injections to establish whether a patients pain is facet joint related and whether the patient is a possible candidate for radiofrequency ablation procedure in the future. Therefore, the requested bilateral lumbar facet joint injections at L3-4, L4-5 and L5-S1 are 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 61-year-old female enrollee has requested authorization and coverage for mastectomy bra and prosthesis for left breast. As noted by the American Society of Plastic Surgeons (ASPS), cosmetic surgery is performed to reshape normal structures of the body in order to improve a patients appearance and self-esteem. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. Reconstructive procedures are generally performed to improve function, but may also be done to approximate a normal appearance. This patient presents with an abnormal structure with significant breast asymmetry as the result of treatment for left breast cancer. The patients previous partial mastectomy, followed by radiation therapy, complicated by infection and wound healing problems, has resulted in an abnormal appearance and volume of the left breast. Due to significant asymmetry, she was considered for breast reconstruction, but was recommended for weight loss prior to reconstruction. Thus, an external prosthesis and mastectomy bra were recommended. The requested external prosthesis and mastectomy bra will help to approximate a normal appearance. Thus, the requested mastectomy bra and prosthesis for left breast are supported as medically necessary for treatment of this patients medical condition status post partial mastectomy. 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 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: Upheld

The patient has requested authorization and coverage for shoulder surgery. Researchers concluded that there is limited evidence that surgery is more effective in treating rotator cuff tear than conservative treatment alone. Thus, the providers recommend a conservative approach for initial treatment. This patient presents with chronic grade 10/10 left shoulder pain, significant loss of range of motion, and weakness. The patient reports functional limitations with activities of daily living. Clinical examination findings are consistent with imaging evidence of rotator cuff tendinopathy and adhesive capsulitis. Conservative treatment has included activity modification, medications, and home exercise. A corticosteroid injection was performed with no documentation of response or follow-up. The provider reports that given the patients lack of ability to engage in physical therapy, surgery might be more complicated and have a worse outcome. Overall, there is an absence of a specific treatment plan and documentation of post-injection follow-up to support an indication for surgical intervention. Based on the available records, the requested shoulder surgery is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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.