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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Zepatier for treatment of the enrollees hepatitis C virus. 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 when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 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: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for residential treatment center (RTC) services that were provided from 12/12/18 through 12/16/18. The patient was admitted to the RTC service on 11/17/18 and was discharged on 12/17/18. Her diagnoses included alcohol use disorder. The American Psychiatric Association (APA) treatment guidelines for Substance Use Disorders recommends that RTC or similar care that is higher than outpatient is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use...lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. In addition, the American Society of Addiction Medicine (ASAM) supports individualized, person-centered treatment that is responsive to specific needs and patient progress rather than focusing on placement in a program with a fixed length of stay, moving from program-driven to clinically driven and outcomes-driven treatment. The ASAM criteria is a set of objective guidelines used by providers to assist with treatment planning. The ASAM advocates for services provided in the least intensive, but safe treatment setting possible for each individual patient. The purpose of detoxification is to make the patient physically stable and safe. Rehabilitation is the essential component that should follow detoxification to help the patient maintain sobriety and reduce the risk of relapse. The RTC was in accordance with generally accepted standards of medical practice.This patients risks included her living alone without a support system in place. She required a safe and stable living environment in order to develop her recovery skills, and thus qualified for ASAM Level III treatment, which is consistent with the services provided at the RTC. Therefore, the RTC services provided from 12/12/18 through 12/16/18 were medically necessary to treat the patients behavioral health condition.Final Result: The reviewer determined that the requested services were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry 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 of Marinol for treatment of the enrollees chronic obstructive pulmonary disease. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  There is little to no literature on the role of marijuana or cannabinoids in the management of breathlessness as a complication of advanced lung disease, largely because research on this family of drugs is limited. To date, the evidence demonstrates some benefits for cannabinoids in symptom relief for chronic neuropathic pain, cancer pain and multiple sclerosis related spasticity, otherwise the data was graded as low or very low quality. Further, the reported adverse effects often were more debilitating than  the disorder being treated. There is also limited evidence that cannabis differed from cannabinoids in effect or adverse effect. Lastly, regarding the issue of breathlessness, the scientific data is limited to the single cited study, which evaluated 224 normal and 68 COPD subjects exposing them to room air and varying concentrations of carbon dioxide to induce a sensation of breathlessness. Cannabinoids, in this case a nasal spray combination of tetrahydrocannabinol and cannabidiol, led to no changes in breathlessness or sensitivity to carbon dioxide. However, patients with COPD when asked to describe their breathlessness related some amelioration of the unpleasantness of breathing. In total, the investigators summarized that cannabinoids had no effect on simulated breathlessness. In this patients case, there is a lack of evidence in his medical records to support a prescription for Marinol. Moreover, the medical literature indicates that he runs a reasonable risk of suffering adverse effects from the drug. Breathlessness is common in advanced lung disease. As such, the standard treatment for this condition is a multistep approach in its management which may include aggressive bronchodilator therapy, consideration of immunomodulators (azithromycin), pulmonary rehabilitation, evaluation for sleep disordered breathing, optimization of cardiac disease (congestive heart failure or ischemia) and treatment of any comorbid depression or anxiety. Therefore, based on current medical evidence and this patients documentation, Marinol is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: The patient has requested authorization and coverage for Talicia 10-250-12.5 mg (four capsules every eight hours for 14 days). Chey and colleagues note multiple options for the first-line treatment of Helicobacter pylori including bismuth quadruple therapy, concomitant therapy consisting of a proton pump inhibitor (PPI), clarithromycin, amoxicillin, and metronidazole, or clarithromycin triple therapy. A rifabutin-based salvage regimen may be recommended after other treatment failures. In this case, given that the records do not show trial and failure of first-line regimens, the requested medication is not medically indicated. Therefore, Talicia 10-250-12.5 mg (four capsules every eight hours for 14 days) is not medically necessary for the 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested gastric bypass (gastric sleeve bypass) surgery for treatment of his medical condition.  Findings: The physician reviewer found that the patient meets all nationally recognized standard criteria for bariatric surgery, including all indications in the National Institutes of Health guidelines. The patient is morbidly obese, over the age of 18, has failed dietary efforts and has completed a thorough multidisciplinary evaluation that did not reveal any overt medical, dietary or behavioral contraindications to surgery. The patient was originally denied as a candidate for surgery, secondary to smoking however, a more recent multidisciplinary evaluation demonstrated that the patient has quit smoking for an extended period of time.  At the subsequent multidisciplinary evaluation, the patient was determined to be prepared for surgery. Consistent with these findings, the requested procedure is medically necessary for management of this patients medical conditions.   Final Result:  The reviewer determined that the requested procedure 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 surgery, with a sub-specialty in bariatric surgery, and is actively practicing.  The reviewer is knowledgeable in the treatment of the enrollees medical condition, knowledgeable about the proposed treatment, and familiar with guidelines and protocols in the area of the treatment under review.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the graft product, acellular dermal matrix (ADM) implantation utilized during surgery for treatment of her fracture of dislocation of left fourth proximal interphalangeal joint with volar plate involvements and left carpometacarpal arthritis. Three physician reviewers found that Ellis and Kulber noted that 'upper extremity surgeons have long been challenged with finding the best tissue replacement for weakened, ruptured, or diseased tendons and ligaments. Kokkalis and colleagues described an alternative to using native tendon by reporting the use of acellular dermal matrix to suspend the first metacarpal, thereby eliminating donor-site morbidity. Thus, AlloDerm has been used in an attempt to replace the use of autologous tendon tissue for the interpositional graft. However, from a review of the literature, this has not been sufficiently studied to replace generally accepted treatment for CMC arthroplasty. Accordingly, the graft product, ADM implantation was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the services at issue were not likely to be more beneficial for treatment 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 orthopedic surgery and is actively practicing. Two reviewers are board certified in plastic surgery 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral Monovisc injections (CPT-J7327) for both shoulders. Findings:  The physician reviewer found that Common nonoperative management of osteoarthritis include nonsteroidal anti-inflammatory drugs (NSAIDs), and intra-articular injection of corticosteroids. Intra-articular injection of hyaluronic acid has become accepted as an alternative treatment for the management of osteoarthritis.  A study by McKee and colleagues found, preliminary evidence that a single injection of non-animal hyaluronic acid may be efficacious over 6 months and well-tolerated in patients with symptomatic glenohumeral (shoulder) osteoarthritis. Moreover, Kany and colleagues indicate, Viscosupplementation allows implantation to be postponed until the shoulder becomes stiff and painful. In this case, the patient presented with bilateral shoulder pain. Additionally, the patient has a known history of osteoarthritis in both his shoulders. Due to his age, the patient desires to postpone bilateral shoulder replacement surgery. Therefore, the requested bilateral Monovisc injections (CPT-J7327) for both shoulders are medically necessary for treatment of the patients medical condition. 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

A 54-year-old female enrollee has requested BRCA 1 and BRCA 2 genetic testing for evaluation of her breast cancer.  Findings:  The physician reviewer found that BRCA testing is important in clinical oncology because bilateral mastectomy would eliminate a carriers chance of developing breast cancer. Likewise, closer surveillance for ovarian cancer can be applied or the patient may choose salpingo-oophorectomy which would reduce the probability of developing this cancer. Currently, genetic testing is indicated for patients that have family histories suggestive of inherited predispositions. Frank and colleagues performed BRCA testing in 10,000 patients and related the presence of mutations to the family history. The authors reported that family history included at least one first- or second-degree relative with breast or ovarian cancer. Thereafter, no distinction is made. This study is impressive for its size and for its separate analysis of individuals with Ashkenazi and non-Ashkenazi descent. This patients records do not document any signs of increased risk such as contralateral breast cancer, ovarian pathology, or Ashkenazi ancestry. For these reasons, the requested BRCA 1 and BRCA 2 genetic testing is not medically necessary for evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The advantage of tomosynthesis relates to the ability it allows radiologists to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers. For this reason, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had the exam been done with two-dimensional technique alone.  Final Result: Two 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: All three physician reviewers are board certified in diagnostic radiology 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the pelvis and abdomen, with or without contrast (CPT code 72197 and 74183). The submitted documentation supports that the requested services are medically necessary. Magnetic resonance imaging (MRI) of the abdomen and pelvis is required in order to perform magnetic resonance (MR) enterography. Given that the provider has noted that capsule endoscopy may be performed at the time of endoscopy and colonoscopy, MR enterography has the additional benefit of assessing whether the capsule would be at risk of retention. In this case, the patients previously normal laboratory testing was cited by the Health Plan as a reason not to perform MR enterography. However, in pediatric patients, it is not uncommon for all blood testing to be normal at the time of diagnosis. Recent guidelines for diagnosis and management of Crohns disease in children state that normal blood tests do not exclude a diagnosis of IBD. Accordingly, MRI of the pelvis and abdomen, with or without contrast (CPT code 72197 and 74183), is medically necessary to treat the patients medical condition.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 pediatrics, with subspecialty certification in pediatric gastroenterology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested nighttime licensed vocational nurse (LVN) services for treatment of her medical condition. Findings:  The physician reviewer found ALS is a progressive neurodegenerative disorder that causes muscle weakness and disability, with a median survival of three to five years. Symptomatic management is the mainstay of treatment for ALS. Skilled nursing care, according to Medicare benefit policy manual, includes care for a G-tube and suctioning via a tracheostomy. In this case, the patient suffers from a neurodegenerative disorder and further decline in her function and medical condition is expected.  The patient has a tracheostomy and requires regular suctioning overnight to maintain a patent airway. Care for both a feeding tube and a tracheostomy can be taught to a layperson, however, it is medically necessary to provide the care of a skilled nurse while that layperson (caregiver) is sleeping.  Therefore, nighttime LVN services are medically necessary in this clinical setting. 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 internal 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: Upheld

A 55-year-old female enrollee requested authorization and coverage of a vertebroplasty for the treatment of osteoporosis and vertebral compression facture.  The health plan denied the enrollees request indicating that the requested vertebroplasty is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  All three-physician reviewers concluded that the requested vertebroplasty is not likely to be more beneficial for treatment of the enrollees vertebral compression facture than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 63-year-old male enrollee has requested reimbursement for hospital stay for treatment of the enrollees hyponatremia and dehydration.  Findings:  the physician reviewer found that The hospital stay provided was not medically necessary for treatment of the patients medical condition. The documentation provided for review shows that the patients sodium level was 131 with a BUN of 27 and creatinine of 1.8. There is no documentation to show any symptoms associated with hyponatremia. The patient at baseline has chronic kidney disease. There is no indication that the patient had any vomiting or persistent dehydration after initial IV fluids at a lower level of care or that the patient required any parental nutrition. The sodium was not below 120 or greater than 150. There was no evidence of hemodynamic instability such as tachycardia or hypotension at the time of admission. There is no documentation that the patient failed to be adequately treated at a lower level of care. Inpatient admission was not medically necessary in this case. Inpatient care is necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. 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 internal 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.