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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his 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 applies regardless of fibrosis stage or viral load. 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/IDSA guidelines cite data showing reduced survival with delayed treatment. As such, the requested treatment with Harvoni 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 authorization and coverage for Orthovisc injections to both knees. Researchers found that intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. A study recommends hyaluronan acid for appropriate patients with knee osteoarthritis, based on a very large network. Evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement and is more effective. There is no detailed evidence of recent failed conservative treatment. Additionally, there is no current pain or functional assessment. Under these circumstances, Orthovisc injections to both knees are not medically necessary for the 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.Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee, with glioblastoma aphasiahas, requested authorization for brain surgery and related services performed at UCSF.Findings:  The physician reviewer found that clinical evidence does not demonstrate the patients brain surgery was necessary on an emergent or urgent basis at UCSF. . There was no urgency indicated in the medical record. The patient did not undergo surgery until a week after being admitted to the ER. She could have been safely transferred to an in-plan facility for her brain surgery. There is no demonstrable evidence indicating a need to have the surgery performed at UCSF.
Appeal type: Medical Necessity
Decision: Overturned

A 38-year-old female has requested an MRI of the lower extremity, any joint, without contrast materials (CPT code 73721) for evaluation of her ankle pain. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested diagnostic procedure in this patients case.  This patient is status post osteotomy of the ankle and a tendon transfer.  The evaluation of osteochondral defects and tendon pathology in the ankle is an established indication for an MRI of the ankle. While a CT scan may evaluate the extent of osteochondral defect, an MRI allows for secondary evaluation, including persistent fluid deep to the defect indicating instability.  An MRI is also useful in the evaluation of tendinopathy or tenosynovitis, although a CT scan is not beneficial in this setting.  In this patients case, the current medical evidence supports the requested MRI.  All told, an MRI of the lower extremity, any joint, without contrast materials (CPT code 73721) is medically indicated in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 47-year-old male enrollee has requested anterior optical coherence tomography (OCT) testing for treatment of his medical condition.  Findings:  Three physician reviewers found the anterior optical coherence tomography was not likely to be more beneficial for treatment of the patients medical condition than any available standard treatment. The standard therapy for a patient with anatomically narrow angles is comprehensive ophthalmologic examination with the addition of gonioscopy to evaluate the anterior chamber angle. The medical literature confirms that further studies are needed to clarify whether anterior optical coherence tomography findings are useful for glaucoma management (Sharma et al). At this time, gonioscopy is the standard of care for evaluating and monitoring the patients narrow angles and there is insufficient evidence that anterior optical coherence tomography was likely to be of greater clinical value than gonioscopy. Therefore, the anterior optical coherence tomography was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old female enrollee has requested authorization and coverage for Y90 radioembolization for treatment of her metastatic ocular melanoma. Findings:  Two physician reviewers found that the current medical evidence has not demonstrated that the requested Y90 radioembolization is likely to be superior to other available treatment modalities.  Gonsalves and colleagues noted that further investigation is needed to determine whether radioembolization should be used as an alternative first-line treatment for hepatic metastasis of uveal melanoma.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee has requested for a positron emission tomography (PET) with computed tomography (CT) scan every 2 months for evaluation of her inflammatory breast cancer.  Findings:  The physician reviewer found that the utilization of PET/CT meets criteria as defined by the Centers for Medicare and Medicaid Services (CMS), which is the generally accepted standard of care in this setting. Specifically, PET is covered for restaging after completion of treatment for the purpose of detecting residual disease, for detecting suspected recurrence or metastasis, or to determine the extent of a known recurrence. In general, restaging applies to testing after a course of treatment is completed. CMS further recommends PET/CT scanning when it is expected that conventional studies will be insufficient for the clinical management of the patient and PET/CT could potentially obviate the need for the standard imaging. This patients records document that CT alone was insufficient in that it was not sensitive enough to detect the liver metastases subsequently visible on PET/CT. In addition, the PET/CT findings were confirmed with a liver biopsy that demonstrated metastatic disease. Thus, it remains likely that conventional CT would continue to be inadequate for restaging purposes, while PET/CT would be more instructive to guide this patients care.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old male enrollee has requested exposure and response prevention (ERP) therapy, in conjunction with sibling and family mental health therapy for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found the submitted documentation establishes the medical necessity of the requested therapies. Based on the documentation submitted, the patient has obsessive-compulsive disorder (OCD), generalized anxiety disorder, and mood disorder not otherwise specified. The exposure and response prevention has had a significantly positive impact on reducing not only his overall anxiety level, but also has his obsessive compulsive symptoms. Specifically his obsessional stuckness and perfectionism appears to be breaking down in terms of its rigidity through this treatment. Thus, the requested therapies are specific to stimulus exposure/response prevention, which is medically indicated in this patients case. As such, the medical necessity of the requested exposure and response prevention (ERP) therapy, in conjunction with sibling and family mental health therapy has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 42-year-old male diabetic with erectile dysfunction. The patient indicates his condition has responded to treatment with Viagra in the past. He has requested authorization and coverage for Viagra. The Health Plan has denied the patients request on the basis that Viagra is not medically necessary for treatment of the patients medical condition.Diabetes mellitus is a recognized and documented cause of organic erectile dysfunction. Treatment with PDE-5 inhibitor medications is accepted primary therapy for treatment of erectile dysfunction and is often successful. If not contraindicated by concomitant use of organic nitrates or drug intolerance to the medication, the patient should be treated with Viagra. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old female enrollee has requested for a laparoscopic adjustable gastric banding for treatment of her morbid obesity.    Findings:  The physician reviewer found that the 2004 Bariatric Surgery Consensus Conference Statement recommends serious consideration of bariatric surgery for obese patients with a BMI 30 to 34.9, especially when a condition exists which can be markedly improved by substantial and sustained weight loss.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a 5-year-old male enrollee has requested relationship developmental intervention (RDI) for treatment of the enrollees autism. Findings:  Two physician reviewers found the requested services are not likely to be more effective for this patient than other available options. The medical literature strongly supports the treatment of autism with ABA therapy in children. ABA therapy has been documented, in multiple studies, to significantly improve motor, verbal, and social interactive skills in autistic children. A review of the medical literature reveals a lack of independent studies on RDI and clinical evidence to support the efficacy of RDI interventions. In the absence of adequate clinical evidence in the peer-reviewed literature that supports the efficacy of RDI interventions, it is not possible to conclude that RDI is likely to be more beneficial than standard therapies available in this setting. Therefore, the requested services are not likely to be more beneficial for this patients autism than standard treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Review of the patients records demonstrates the patient has previously received physical therapy for her condition without improvement. The patient began receiving physical therapy involving manual therapy techniques in November 2003. The submitted treatment notes indicate the patient experienced some ups and downs in her condition, but there is no documentation of any objective improvement (e.g., ability to sit for longer periods of time or tolerate intercourse). In a letter dated 4/16/04, the patient indicated she had recently begun to experience some improvement in her symptoms. She has requested authorization for continued physical therapy utilizing manual therapy techniques. The Health Plan has denied her request indicating the requested therapy is not medically necessary for treatment of the patients medical condition.The submitted medical literature does not contain any research studies establishing manual therapy is of proven benefit for the patients condition. The articles primarily discuss the validity of vulvodynia and summarize treatments that have been used. In addition, a review of the relevant literature demonstrates there is no case-controlled, randomized study supporting the efficacy of manual therapy techniques. Furthermore, the submitted therapy notes do not document objective improvement or indicate end points to treatment. Thus, there is no medical indication for continuation of the requested therapy.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 38-year-old male enrollee has requested Lyrica for treatment of his nerve pain secondary to reflex sympathetic dystrophy (RSD).  Findings:  The physician reviewer found that this patient has chronic pain syndrome without a clear diagnosis. The submitted clinical information does not support a diagnosis of chronic regional pain syndrome or RSD. A dermatomal somatosensory evoked potential study is not a standard diagnostic test and results have unclear implications. Furthermore, there is no evidence that this patient has received standard medical therapies such as physical therapy, muscle relaxants and anticonvulsants in the past two years. Moreover, there is no clinical data to suggest that Lyrica is effective in treating chronic non-neuropathic pain.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old female enrollee has requested closure of lacrimal punctum/tear duct plugs for treatment of her dry eye syndrome. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services. Treatment of this patients dry eye syndrome with punctual plugs is medically necessary in this case. The patient has a history of pain and dryness of the eyes and frequent use of artificial tears. Her examinations have shown prominent signs of dry eye, including damage to the corneal epithelium and the development of filaments. The patient was treated with both increase in artificial tears and topical cyclosporine (Restasis), but symptoms persisted. In addition, the letter indicates that guidelines have not been met due to a lack of Schirmers or tear breakup testing, however the medical evidence submitted for review does not support this as a prerequisite to plug placement. Finally, punctal plug placement is the standard of care in this clinical setting and the patient is a good candidate for punctual plug placement. In sum, based on the medical records submitted for review, the patients request for closure of lacrimal punctum/tear duct plugs is medically necessary. Therefore, the medical necessity of the requested services has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old male enrollee has requested for the medication Arimidex for treatment of the enrollees short stature. Findings:  The physician reviewer found that the literature cited in the endocrinologists letter raises no concern over possible side effects and supports a high probability that this treatment will be effective for the patient. Additionally, at the Annual Meeting of the Endocrine Society in Toronto, Canada. The presenters spoke favorably about the use of aromatase inhibitors to promote an increase in adult height in otherwise normal but short boys and in boys with constitutional growth delay. All told, there is sufficient evidence of the benefit of Arimidex to warrants its use in this setting.
Appeal type: Experimental/Investigational
Decision: Overturned

A 59-year-old male enrollee has requested for intensity modulated radiation therapy (IMRT) for treatment of his esophageal cancer. Findings:  Two physician reviewers found that IMRT is a tool that clinicians can use when there is concern about sparing normal tissues from high dose exposure. There is a growing body of literature on the use of IMRT for esophageal cancer, with most studies suggesting a dosimetric advantage of IMRT versus conventional 3-dimensional (3-D) radiation. IMRT is a tool that enables the reduction of dose to surrounding organs. While there is a lack of literature explicitly demonstrating that IMRT for esophageal cancer results in superior outcomes versus 3-D radiation techniques, it becomes necessary to utilize IMRT when conventional 3-D radiation plans are inadequate. IMRT often allows clinicians to safely treat tumors when adequate sparing of normal structures cannot be achieved with conventional 3D radiation techniques, which appears to be the case with this patient in terms of dosing to the lung. As such, the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 58-year-old male enrollee has requested for a FIBROSpect II blood test for evaluation of his hepatitis C.  Findings:  Two physician reviewers found that in clinical trials, the FIBROSpect II has been shown to have a very good positive predictive value for the absence of significant fibrosis (F0-1) when the score is low, with many studies demonstrating the correlation.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old female has requested Botox injections for treatment of headaches.  Findings:  Three physician reviewers found that Botox has considerable data consistent with a positive benefit as a migraine preventive, especially when the frequency of attacks is high (chronic migraine). However, Botox is only indicated after standard therapies such as beta-blockers or tricyclics have been tried and failed.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency department services provided. Findings:  The physician reviewer found that based on the documentation submitted for review, the patient received emergency medical services during the date of service at issue. The U.S. Department of Veteran Affairs practice guidelines for the assessment and management of patients at risk for suicide indicate that anxiety is a significant and modifiable risk factor for suicide, and benzodiazepines with a short half-life, such as alprazolam, should be avoided. In this case, the patient presented acutely anxious. She was experiencing chest pain, was suicidal, and she was out of her medication. She had multiple external anxiogenic stressors. In addition, the patient was experiencing concerning somatic symptoms and more than likely a discontinuation syndrome from the selective serotonin reuptake inhibitor and the short-acting benzodiazepine. The patient required emergent evaluation to properly evaluate her psychiatric condition, stabilize her acute distress, rule out medical etiologies and determine the most appropriate level of care. Further, the emergency services were reasonably expected to improve the patients condition and prevent a more severe episode of illness. Therefore, the services at issue were necessary for treatment of a psychiatric emergency medical condition. Thus, the patient received psychiatric emergency medical services on the date of service at issue.Final Result: The reviewers determined that the patient received psychiatric emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one 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

A 51-year-old female enrollee requested authorization and coverage of trigger point injections. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of her neck 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 therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for brand name Anucort-HC 25 mg suppositories. The American College of Gastroenterology (ACG) guidelines for management of benign anorectal disorders do not support use of Anucort suppositories for proctalgia. Moreover, Anucort suppositories are not recommended for the treatment of IBS. Guidelines from the American Society of Colon and Rectal Surgeons (ASCRS) report that rectal corticosteroids are safe and effective for the treatment of hemorrhoids and ulcerative colitis, but neither is documented in this patients case. Additionally, the peer-reviewed medical literature has not demonstrated that the brand name formulation is safer and more effective than the generic formulation. All told, the requested brand name Anucort-HC 25 mg suppositories are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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.