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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for methylenetetrahydrofolate reductase (MTHFR) mutation testing  for evaluation of the enrollees neuro immune syndrome. Findings:  The physician reviewer found that the use of the MTHFR gene mutation testing is commonly used in patients who need to be assessed for hypercoagulability disorder. Based on the documentation provided, there is no evidence that the patient presents with symptoms concerning for hypercoagulable state. The patient has been diagnosed with Lyme disease, anxiety, fatigue and Streptococcus group A. There is a lack of medical literature which supports the use of MTHFR mutation testing in patients that have been diagnosed with this patients diagnoses. As such, the patient was not likely to benefit from the testing at issue. For the reasons provided, the MTHFR mutation testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the testing at issue was 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an Orthovisc injection series in both knees.Findings: Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, Platelet Rich Plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. 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 chronic osteoarthritis of both knees. Documentation reflects that conservative treatment has failed to relieve the patients pain with the exception of viscosupplementation that was beneficial for several years. Records show that the patient has a history of substantial relief from prior injections on multiple occasions. Furthermore, the patients options are limited, with the alternative being surgery. Under these circumstances, the requested Orthovisc injection series in both knees is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for the patient's 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

A 28-year-old male enrollee has requested outpatient mental health sessions at a frequency of four times per week (rather than the approved two sessions per week) for treatment of his major depressive disorder.  Findings:  The physician reviewer found that the submitted information fails to establish the medical necessity for the requested level of service. The patient contends that his depression is mild, but the provider contends it is severe. A psychiatric evaluation in accordance with American Psychiatric Association practice standards was not submitted for review, and progress notes were not provided. Details regarding the patients history, condition and treatment plan are lacking. There is no evidence that the patient has been hospitalized or is at imminent risk for inpatient treatment. All told, outpatient mental health sessions at a frequency of four times per week during the dates in question and continued outpatient mental health sessions at a frequency of four times per week were not and are not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization program services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The progress notes do not indicate that the patient had active suicidal or homicidal ideation. The records do not demonstrate that the patient was experiencing psychosis. The patient showed variable insight into her behaviors. She was withdrawn in group sessions at times. The progress notes do not indicate that the patient was engaging in aggressive behaviors. The patients family was involved in her treatment on a regular basis, and she denied illicit substance use. In cases such as this, an evidence-based, objective instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 1 due to a lack of current suicidal ideation and no self-harming behaviors. With regards to functional status, the records support a score of 2 due to problems with role performance and ability to maintain some meaningful relationships. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability and no substance use issues. With regards to level of stress of the recovery environment, the records support a score of 2 due to a stable living situation with intermittent interpersonal conflict. In terms of level of support of the recovery environment, the records support a score of 2 due to family support and availability of treatment resources but also some difficulty in relationships with her family members. With regards to treatment and recovery history, the records support a score of 3 due to recent success at the inpatient and residential treatment levels of care but without complete remission of the eating disorder symptoms. In terms of engagement and recovery status, the records support a score of 2 to 3 due to cooperation in treatment but also hesitation in acceptance of her illness. Thus, the patient has a composite score of 14 to 15. This score correlates with high intensity community based services, or treatment in an intensive outpatient clinic setting. Therefore, partial hospitalization program services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested radiofrequency ablation (RFA) on the third occipital nerve for medical treatment of her occipital neuralgia. Findings:  Three physician reviewers found that in the documentation available for review, the patient underwent a medial branch block of the C2 and C3 facet joints that did not give her any sustained relief for the duration of the local anesthetic. The third occipital nerve can be a cause of headaches and can be improved with RFA in well selected patients (Hamer and Purath). However, the records indicate that this patient did not obtain the relief that would be necessary to suggest that the RFA would be helpful (Bogduk and Marsland; Derby, et al). Consistent with these findings, the requested RFA of the third occipital nerve is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi and Daklinza 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. In treatment-naive genotype 3 patients (regardless of interferon eligibility), therapy is recommended with Sovaldi and Daklinza for 12 weeks. This is based on the ALLY-3 study, which showed a cure rate of 97% (Nelson, et al; Hezode, et al). Delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, the requested treatment with Sovaldi and Daklinza is medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested genetic testing for evaluation of his medical condition.  Findings:  Three physician reviewers found that in general, the practice of pharmacogenetics, or the tailoring of a medication regimen based on an individuals genetic organization, may well become a valuable tool in the treatment armamentarium for those plagued with psychiatric illness.  However, despite its promise, pharmacogenetics is not yet ready for mainstream clinical application.  In this case, the patient showed some signs of clinical improvement and was not experiencing an acute psychiatric syndrome at the time of the testing.  It appears that substance use and treatment adherence, rather than medication efficacy, significantly contributed to the patients suboptimal clinical response.  Notwithstanding, he tried several antipsychotic medications, but there were many others to consider.  Additionally, the patient had been resistive to non-pharmacologic interventions, such as cognitive behavioral or cognitive remediation therapies, family therapy and rehabilitation strategies.  Thus, it cannot be inferred that the patient had exhausted standard treatments available to treat his condition.  All told, genetic testing was not likely to have been more efficacious than other modalities for evaluating this patient.  Final Result: Three reviewers determined that 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:   All three reviewers are board certified in psychiatry 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

A 32-year-old male enrollee has requested anterior lumbar interbody fusion with instrumentation at L5-S1 for treatment of his lumbar pain.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested procedure. To fuse the lumbar spine in the absence of dynamic instability, more than 2 mm on flexion/extension views or severe spinal stenosis for the lumbar spine, is not consistent with standards of good medical practice. In addition, randomized trials have not demonstrated the efficacy of surgical treatment in chronic low back pain and disc degeneration. Brox and colleagues demonstrated conservative care to be equal to lumbar fusion with a return to work rate at 22% in the surgical group compared with 33% in the non-surgical group. The authors concluded that the overall success rates were equivalent. Fairbank and colleagues performed a randomized controlled trial of spinal fusion versus rehabilitation for patients with chronic low back pain and reported no differences between the groups. Finally, in this patients case, there is no evidence of instability or severe spinal stenosis to warrant a lumbar fusion at the L5-S1 level. Based on the medical literature and the documentation submitted for review, the requested procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The representative of an 82-year-old male enrollee requested authorization and coverage of the medication Epogen. The Health Plan denied this request indicating that the requested medication is not medically necessary for the treatment of the enrollees chronic myelogenous leukemia.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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Onfi for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  This patient has had refractory seizures secondary to a focal brain lesion.  The patient has failed treatment with several prior seizure medications.  Onfi was tried and was beneficial.  Onfi has a restricted U.S. Food and Drug Administration (FDA) approval for a very refractory epilepsy syndrome, Lennox-Gastaut. However, the literature shows that it can be beneficial for multiple seizure phenotypes.  There is medical evidence supporting Onfi for focal seizures, and this medication has been beneficial for this patient.  All told, the requested Onfi is medically indicated 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 physician 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her medical condition.  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 applies regardless of fibrosis stage or viral load. Per guidelines, patients with diabetes are high priority for therapy.  The guidelines recommend that treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline 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. AASLD guidelines cite data showing reduced survival with delayed treatment. 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: Experimental/Investigational
Decision: Upheld

A 48-year-old male enrollee has requested for a kyphoplasty for treatment of his vertebral fractures. Findings:  Two physician reviewers found that use of kyphoplasty remains an unproven technique for the management of pathological vertebral compression fractures. Despite promising early results, the overall efficacy of kyphoplasty remains unproven. The proposed procedure remains experimental/investigational procedure in the management of multiple metastatic vertebral compression fractures, and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mepron for treatment of the enrollees diagnosis of Lyme disease. Findings: The physician reviewer found that this patient was being treated for non-specific complaints and was found to have some improvement on current therapy. The consideration of Babesia was made and testing was negative. While it is possible that the patient may have an infection for which no test is available, this patients clinical scenario does not merit Mepron as there does not seem to be evidence of Babesia infection. Accordingly, the requested Mepron is not medically necessary for this patient.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in infectious 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 hysterectomy and removal of a cyst procedure sooner than the scheduled appointment. The records provided for review document that this patient has a history of pelvic pain and menorrhagia. However, the patients hematocrit is within normal limits and is not suggestive of excessive blood loss. In addition, there is no report that the patient has been assessed with endometrial biopsy to assess her bleeding, or laparoscopy to rule out endometriosis and pelvic adhesions. Moreover, there is no indication that the patient has undergone attempts to treat her heavy bleeding with hormonal treatment in the form of combined estrogen-progesterone pills, progestin, tranexamic acid, or endometrial ablation. The provider noted that the patient has refused hormone therapy. Treatment with either tranexamic acid or endometrial ablation is hormone-free. Similarly, a gonadotropin-releasing hormone (GnRH) agonist such as Lupron or antagonist with Orilissa are also hormone-free. This patient does not have a life-threatening condition that requires immediate surgery. For these reasons, the requested hysterectomy and removal of a cyst procedure sooner than the scheduled appointment on 6/24/21 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 obstetrics and gynecology with subspecialty certification in reproductive endocrinology 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.