Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee has requested radiofrequency volumetric tongue reduction for the treatment of his obstructive sleep apnea (OSA). Findings:  Three physician reviewers found that this patient has a complex apnea, a combination of central and obstructive sleep apnea. There is no surgical treatment for central apnea. He has had multiple procedures for his obstructive sleep apnea. These have not helped to relieve the symptoms. As noted in the literature, radiofrequency volumetric reduction of the tongue base usually results in only mild improvement of obstructive sleep apnea symptoms. Furthermore, there is deterioration in these benefits over the long-term. All told, the proposed radiofrequency tongue base reduction is not likely to result in significant or sustained improvement in the patients symptomatology.
Appeal type: Medical Necessity
Decision: Upheld

A-37-year-old female enrollee has for panniculectomy/abdominoplasty, brachioplasty, liposuction and thigh lifts for treatment of her redundant skin condition.          Findings:  The physician reviewer found that the photographs reveal an obese female with multiple body folds, but no evidence of intertrigo, rashes, skin ulceration or hyperpigmentation consistent with chronic skin infections. There is no documentation of conservative management over a period of time with failure of such interventions.
Appeal type: Medical Necessity
Decision: Overturned

The patient is an 11-year-old female who is short (-3.25 SD), did not screen positive for GH deficiency (normal IGF-1 and IGFBP-3 levels) or thyroid disease, and had a normal bone age for chronological age. The patient had a predicted adult height of from 46 to 48 which is akin to the heights seen in untreated Turners syndrome. Thus, this patient would fall into the idiopathic short stature group. DNA analysis of the short stature homeobox or SHOX gene showed a probable deletion of a whole gene and a partial deletion of the other. The patients provider recommended growth hormone therapy. The Health Plan has determined continued use of growth hormone therapy is not medically necessary for treatment of the patients medical condition.The Food and Drug Administration has approved the use of growth hormone therapy for the diagnosis of idiopathic short stature. SHOX gene mutations have been estimated to be present in about 2% of idiopathic short stature cases. Whereas the patient had a normal karyotype ruling out Turners syndrome, she in effect does have a similar genetic lesion affecting the Xpter-p22.32 chromosomal region. Furthermore, the submitted records indicate the patients rate of growth has improved from 3 cm per year to 10 cm per year. For these reasons, continued growth hormone therapy is medically appropriate and indicated.Based upon the information set forth above, 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: Upheld

The patient is a 48-year-old female with chronic dysmenorrhea and premenstrual syndrome (PMS). She reports menses every 30 days with worsening menstrual cramps from 3 days prior and continuing to the third day of her menses. The dysmenorrhea has not been relieved by Darvocet, codeine, Naprosyn, ibuprofen or conventional oral contraceptives. The patient also reports premenstrual symptoms of depression and insomnia that have not responded to Effexor or over-the-counter preparations. The patient was evaluated by a gynecologist in January 2006. She had an ultrasound, which indicated normal uterus and ovaries. Following her evaluation, the patient was placed on Seasonale, which has allowed her to have a menstrual period every three months rather than every month. She apparently has found this to provide significant relief from her symptoms and has tolerated it well. At issue is whether Seasonale is medically necessary.Oral contraceptives are the first-line treatment for dysmenorrhea. Seasonale is a contraceptive preparation containing levonorgestrel 0.15mg and ethinyl estradiol 0.03mg in each active tablet. It is unique in that it is packaged with 84 active tables followed by 7 days of placebo tablets, as compared to conventional contraceptive preparations, which contain 21 active tablets with 7 placebo pills. A patient taking Seasonale will in general have menstrual bleeding (or more accurately withdrawal bleeding) only when taking the placebo tablets, i.e., approximately every three months as opposed to the conventional oral contraceptives where withdrawal bleeding will occur approximately every month. However, any conventional oral contraceptive can be taken continuously for 84 days and thereby allow the patient to experience bleeding every three months rather than every month. In this case, the Health Plan formulary includes the conventional oral contraceptive Levlen, which has the exact formulation as Seasonale. The patient can obtain the same favorable outcome if she takes Levlen continuously, i.e., active tablets for 84 days followed by 7 days of placebo. Thus, Seasonale is not medically necessary as long as three packs of the formulary contraceptive Levlen are authorized at a time.Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition at this time. Therefore, the Health Plans denial should be upheld at this time. Three packs of Levlen should be authorized at a time so there is no interruption in the patients treatment. If the Health Plan does not provide this authorization, the patients request for Seasonale should be reconsidered.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Contrave. Findings:  The physician reviewer found that the request for Contrave is not medically necessary for treatment of the patients medical condition. Contrave was approved by the U.S. Food and Drug Administration (FDA) as an adjunct to diet and exercise in patients with a body mass index (BMI) greater than 30 or greater than 27 in the presence of at least one weight-related comorbidity like hypertension, type 2 diabetes or dyslipidemia. Due to Contrave containing bupropion, the FDA warns of psychiatric disorders, especially in the young adult population. In addition, a randomized trial designed to assess cardiovascular outcomes of bupropion and naltrexone in overweight or obese patients was terminated early and the cardiovascular safety remains unknown. In this case, the patient is treated with bupropion and also takes antidepressant medication. The addition of Contrave to this patients current medication regimen may cause adverse effects. All told, Contrave has not been established as medically necessary for treatment of the 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

A 54-year-old female enrollee has requested Byetta 10mcg for treatment of her type 2 diabetes mellitus.  Findings:  The physician reviewer found that Byetta is appropriately used with insulin by practitioners in the endocrinologic community. A paper showed the benefits of adding Byetta to the regimen of patients already taking insulin(Yoon and colleagues). The authors noted that patients achieved a weight loss of 4.3 kilograms at 6 to 12 months, reduction in Alc of 0.55% at 6 to 12 months, decrease in insulin dose of 14.8 units at 6 to 12 months and decrease of prandial insulin dose of 25.9% at 6 to 12 months. The combination of Byetta and insulin is widely utilized within the medical community, and the article cited above supports the use of Byetta in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old female enrollee has requested a rheumatology referral for the treatment of her osteoarthritis. Findings:  The physician reviewer found that therapy for this condition is classified as either non-pharmacologic or pharmacologic therapy. Examples of non-pharmacologic therapy include self-management programs, such as the Arthritis Self-Help Course, aquatics programs, physical therapy, aerobic exercise programs and bracing. Examples of pharmacologic therapy include several treatments that the patient has already tried and topical analgesics such as capsaicin cream, topical anti-inflammatories and topical lidocaine patches. Exercise and weight loss have been shown to be beneficial in joint function and pain control in older adults. Randomized controlled clinical trials of physical therapy have shown improved clinical outcome in osteoarthritis, with particular benefits from quadriceps strengthening in patellofemoral arthritis. In view of the inadequate pain control in this patient and the lack of evidence in the medical record that important modalities such as physical therapy have been used, a referral to a rheumatologist is medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injection series in the left knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from prior injections. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Orthovisc injection series in the left knee 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 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: Medical Necessity
Decision: Upheld

The enrollee is requesting authorization and coverage for reimbursement for custom removable insert orthotics. The enrollee has bilateral foot pain. He was evaluated by a podiatrist. Records show the x-rays demonstrated degenerative changes and degenerative arthritis. The diagnosis was bilateral primary arthritis, foot pain, and difficulty walking. The enrollee reports the podiatrist prescribed the orthotics to prevent further medical issues. Other than the x-ray findings, there was no physical exam of the feet reported in the medical records for this visit that showed any clinical deformity of the feet, or prominence due to osteophytes, from the arthritic changes noted on the x-rays. Records do not show a history of failed treatments, use of oral non-steroidal anti-inflammatories or any history of steroidal injections for the arthritic joint causing the pain.  A review of the literature regarding custom foot orthotics reveals that, while many studies have been published, the results have been varied, and often inconclusive or negative in nature. Furthermore, the role of over-the-counter orthotics in the relief of pain has been extensively researched. One study found that over-the-counter orthotics have been found to be effective in relieving foot pain. Records do not show any conservative measures having been tried prior to the recommendation of the custom orthotics.Final Result: The reviewer determined that the requested service was not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in podiatry 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

The patient has requested authorization and coverage for transcatheter aortic valve replacement (TAVR) surgery. Based on the available documentation, this patient has severe aortic stenosis by echocardiography and he reports symptoms of increasing fatigue, which are consistent with the marked severity of his aortic valve disease. As he is symptomatic, he meets criteria for aortic valve replacement as a D1 classification as a low-risk surgical patient. Based on his other anatomic studies, he is a good candidate for transcatheter aortic valve replacement by technical criteria. Moreover, the U.S. Food and Drug Administration (FDA) has approved TAVR surgery for low-risk symptomatic surgical patients who require aortic valve replacement. Given this support, the requested TAVR is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested surgery 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 subspecialty 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

A 66-year-old male enrollee requested authorization and coverage of the medication Xenical. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni 90-400 mg for treatment of the enrollees chronic hepatitis C virus genotype 1a.  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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). The AASLD and IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Qudexy XR 100 mg for treatment of chronic pain. Findings:  The physician reviewer found that there is a lack of support for the requested medication in this clinical setting.  The use of topiramate extended release (Qudexy XR) for this patients pain is an off-label use.  Clinical reviews of its efficacy and outcome have failed to showed benefit when compared to placebo in randomized controlled trials. She also did not receive benefit from the immediate release version of the drug and sustained significant side effects, including nausea, dizziness, loss of appetite and blurred vision.  There is a lack of support for the requested medication in this clinical setting. Final Result: The reviewers 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for modafinil tablet 200 mg for treatment of her medical condition. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. There is a lack of documentation demonstrating the patient has OSA. There is no record showing that she is being treated with optimal CPAP in a titration study and that she was compliant with the use of CPAP. There are no Epworth Sleepiness scores documenting daytime hypersomnia despite adequate treatment of OSA. In addition, there is no Multiple Sleep Latency Test (MSLT) that documents that she had a markedly decreased sleep latency with rapid eye movement (REM) sleep during the naps and that she had narcolepsy. 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 sub-specialty certification in pulmonary 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:   An enrollee has requested Levitra for treatment of his testicular hypofunction and erectile dysfunction. The physician reviewer found that currently, there is a lack of evidence in the medical literature that combination therapy with Levitra and daily Cialis is effective for erectile dysfunction. Oelke and colleagues concluded that although monotherapy with tadalafil (Cialis) or tamsulosin resulted in significant similar improvements versus placebo, only Cialis improved erectile dysfunction. All told, the requested Levitra is not supported as 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 urology 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 has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) level of care services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.1 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. The patient meets the six ASAM criteria for treatment at the RTC level of care. For these reasons, the RTC level of care services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty 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.