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

A 37-year-old female enrollee has requested Bystolic for treatment of her essential hypertension. Findings:  The physician reviewer found that from a review of the available records, it appears that the patient had adequate control of her blood pressure for several years but then was changed to Bystolic due to fatigue believed to be secondary to Atenolol. Bystolic is a third-generation beta-1 receptor blocker that has been shown to improve diastolic function and reduce mortality in elderly heart failure patients.Coverage for Bystolic was denied as multiple other beta-1 selective agents were available on the Health Plans formulary. This appears to be a very reasonable cause for denial since the patients records do not indicate that she has been treated with any of these other agents. Furthermore, the use of beta blockers for initial monotherapy in patients with uncomplicated essential hypertension is no longer considered to be optimal except in the post-myocardial infarction patient or heart failure patient population. Alternative therapies include thiazide diuretics, angiotensin converting enzymes inhibitors, angiotensin II receptor blockers, or calcium channel blockers. In view of these multiple considerations, the requested Bystolic has not been demonstrated to be medically necessary for treatment of this patients medical condition. Other medications, available under the patients formulary, would be appropriate for attempts at management in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for 12 weeks for treatment of  her chronic hepatitis C virus genotype 3a. 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. This applies regardless of fibrosis stage. Per the 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 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: Upheld

The patient is a six-year-old female who has been receiving occupational therapy since 2001 for sensory integration and fine motor delays. A progress report from November 2002 reflects moderate sensory integration difficulties and mild fine skill deficits including difficulty buttoning and drawing shapes. Subsequent reports document poor trunk control. The patients therapist indicates the patient experienced improvement from moderate to mild deficits in sensory integration from 2002 to 2004.At issue is whether the therapy the patient received from September 2003 to May 2004 was medically necessary.In reviewing the literature regarding occupational therapy utilizing sensory integration for treatment of developmental delay, there are no controlled studies in support of the therapy. Though relevant papers describe theories, the authors conclude there is a lack of evidence supporting these theories. Thus, although sensory integration therapy is the primary tool used by occupational therapists in the developmental delay population, it is not evidence based. Furthermore, in the case of this patient, the goals defined in the submitted progress reports are not medically based. Most of the goals are educational in nature (e.g., stringing beads, picking up pennies, attention tasks, bouncing balls) and are not very objective. Moreover, the evaluations are one year apart and do not demonstrate significant gains over that year. The gains achieved could just as easily be explained by practice. Therefore, I have determined that the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for gastric bypass revision surgery. The records provided for review do not document the presence of an anatomically correctable pathology. There is no assessment provided for review to determine whether the patients gastric bypass remains intact. For patients who present with a relatively intact anatomy, revision of the gastric pouch or outlet has not been demonstrated to result in durable weight loss. In addition, there is a lack of reported ongoing attempts at weight loss, re-engagement with the multidisciplinary program, or use of any medical adjuncts. Moreover, there is a lack of updated dietary, surgical and behavioral evaluations. For these reasons, the requested gastric bypass revision 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 surgery with expertise in bariatric and minimally invasive 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Norco and MS Contin for treatment of the enrollees chronic low back pain and neuropathy.  Findings: The reviewer found that Felicilda-Reynaldo notes that opioid risk mitigation tools should be part of practice and when patient safety issues are identified such as lack of compliance, lack of adherence to prescription, or aberrant use, opioids should not be continued. Cheung and colleagues noted that opioids are generally not recommended as first-line therapy but, when used, providers should closely monitor patients for loss of response, adverse effects or aberrant behavior, and revise the treatment plan accordingly. Urine drug testing (UDT) may be used as a tool to monitor for aberrant behavior or drug misuse and opioid rotation may be considered, when loss of response or adverse effects are a concern, at a starting dose lower than the calculated equianalgesic dose. Opioids should be tapered when patient safety risks are identified. Overall, peer-reviewed guidelines support opioids with ongoing review and documentation of pain relief, functional status, appropriate medication use, and side effects. Pain assessment should include current pain, the least reported pain over the period since last assessment, average pain, and intensity of pain after taking the opioid, how long it takes for pain relief, as well as how long pain relief lasts. Satisfactory response to treatment may be indicated by the patients decreased pain, increased level of function, or improved quality of life. This patients medical records report chronic pain and progress notes document ongoing opioid risk mitigation tool use. However, the records do not indicate failure of conservative treatment in support of opioid therapy. Congruent with current guidelines, chronic opioids are not indicated for treatment of this patients chronic pain. All told, the requested Norco eight tablets per day and MS Contin one tablet per day are not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested medications 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 neurology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested fecal DNA testing for evaluation of her risk for colorectal cancer.  Findings:  Three physician reviewers found that Cologuard is U.S. Food and Drug Administration (FDA) approved for screening for colon cancer. Cologuard has been demonstrated to be 92% sensitive for the detection of colon cancer, and is able to detect most adenomas with high-grade dysplasia. The use of the test is recommended by the American Cancer Society (ACS) for colon cancer screening. Based on the clinical literature and current guidelines, in this patient with a history of adverse issues during prior colonoscopy, the fecal DNA testing was likely to have been more beneficial for evaluation of her medical condition than any available standard therapy. Final Result: 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One reviewer is board certified in pediatrics with sub-specialty certification in genetics and is actively practicing.  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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

The patient is a 45-year-old male who is on maintenance hemodialysis for end-stage renal disease due to focal segmental glomerulosclerosis and a failed first transplant. He is on a cadaveric transplant waiting list, but has reduced chances of obtaining such a transplant because of a high plasma renin activity (PSA). The patient received two doses of IVIG, which reduced the sensitization parameters insignificantly. A request has been made for authorization and coverage for participation in the Transplant Immunotherapy Program at Cedars-Sinai. The Health Plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the patients condition.Recent literature in relatively small series of patients supports the use of IVIG, plasmapheresis and rituximab to desensitize patients such as this patient and facilitate transplantation. Renal transplant is superior to dialysis as a treatment modality in end-stage renal disease. All attempts should be made to facilitate difficult transplants. Though successful transplantation is not guaranteed, the patient is best served by full doses of IVIG, plasmapheresis and rituximab. The treatment protocol proposed by Cedar-Sinai is medically appropriate and indicated for this patient. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a male with lower back pain. His pain worsens with physical activity and improves with rest. Pain radiates down his left leg intermittently and pain is beginning to affect the right leg. The patients symptoms have progressed despite epidural steroid injections and physical therapy. Magnetic resonance imaging of the lumbar spine showed narrowing and desiccation at L5-S1, which is consistent with degenerative disc disease and paracentral disc protrusion on the left that contacts the traversing S1 nerve root. The disc collapse also caused left sided neural foraminal narrowing. The patient has requested authorization and coverage for spine surgery. The Health Plan has denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether spine surgery is medically necessary for the treatment of this patients medical condition. This patient has mechanical lower back pain, which increases with activity and improves with rest. His back pain is due to degenerative disc disease at L5-S1. Decompressive surgery such as a laminectomy or microdiscectomy will not address back pain due to degenerative disc disease. The options for treating degenerative disc disease include lumbar fusion versus lumbar disc arthroplasty. Given his young age, a fusion would likely cause acceleration of degenerative changes at adjacent levels, possibly leading to a subsequent fusion operation or other surgeries. Lumbar disc arthroplasty would preserve motion at the L5-S1 level and not increase stress at adjacent levels. Medical evidence supports the requested services in this clinical setting. Therefore, the requested spine surgery is medically necessary for the 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400-100 mg tablets for 12 weeks. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier (with ribavirin for 16 weeks when NS5A resistance is found) and Epclusa for 12 weeks. The guidelines recommend Epclusa for 12 weeks based on high safety and efficacy in clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 infection regardless of fibrosis stage.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the walk aide, functional electrical stimulator (FES) HCPCS A4595 (TENS suppl 2 lead per month) and HCPCS E0770 (FES NOS) for treatment of her multiple sclerosis.  Two physician reviewers found that the walk aide or functional electrical stimulation (FES) device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Cameron and Wagner wrote FES for foot drop reduces energy consumption and improves walking speed, distance, and efficiency in people with MS. The patient has used the walk aide and noted such improvement in walking distance. In another study of the use of FES and ankle foot orthoses for gait abnormalities in multiple sclerosis, Bulley and colleagues state On balance, the impacts of the devices [FES and ankle foot orthoses] on improving activities and participation were more important for participants than practical barriers, highlighting the importance of combining understanding of individual experiences and preferences with clinical decision-making when prescribing a device to manage foot-drop.  Given the functional gains of utilizing walk aide and the patients reported functional benefits with the walk aide device, the requested device is likely to be more beneficial for treatment of her condition than any available standard therapy.   Final Result: Two reviewers determined that the requested device 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 physical medicine and rehabilitation and is actively practicing.  Two reviewers are board certified in physical medicine and rehabilitation and neuromuscular medicine 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for eight hours per month of clinical team meetings. Based on the available documentation, this patient is engaging in few, if any, problem behaviors. The records report one tantrum in six months, zero incidents of aggression and property destruction per hour, and .02 incidents of self-injury and elopement per hour. The patients provider has recommended eight hours of clinical team meetings per month as part of her applied behavioral analysis (ABA) treatment regimen. The Behavior Analyst Certification Board (BACB) guidelines do not include team meetings as part of an ABA treatment plan. The BACB guidelines highlight that a review of programs can occur without the patient but can also occur with the patient present. Moreover, the requested clinical team meetings do not meet the medical necessity criteria outlined by Papatola and Lustig. The authors noted that medically necessary services include health-care services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. Applying these guidelines, this patient does not meet the requirements or (a) or (c). Specifically, the requested services are not required to meet the essential health needs of the patient and are not consistent with scientifically based guidelines as determined by medical research. All told, the requested eight hours per month of clinical team meetings are 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 a licensed B.C.B.A, board certified in psychology, 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 55-year-old male enrollee requested authorization and coverage of the medication Actiq. The Health Plan denied the enrollees request indicating that the requested medication is not medically necessary for treatment of the enrollees back and leg pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyaluronan injections for the right knee. According to the current practice guidelines for knee arthritis from the American Academy of Orthopaedic Surgeons (AAOS), hyaluronic acid is no longer a recommended treatment for knee arthritis. Fourteen hyaluronic acid (HA) studies were analyzed, and it was noted that a few individual trials found statistically significant treatment effects, but when combined in a meta-analysis, the evidence did not meet the minimum clinically important improvement (MCII) thresholds. It was conceded that there might be some subgroup of responders who could be helped by HA, but that subgroup has not yet been identified. In this case, there is no rationale presented in the submitted clinical documentation to support an approach that is contrary to AAOS guidelines. Accordingly, the requested hyaluronan injections are not medically necessary for treatment of the patients medical condition.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.