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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for intravenous immunoglobulin (IVIG) Gammaplex 15 grams weekly for three to six months. This patients medical records include a history and presentation that support diagnoses of Ehler-Danlos syndrome, postural orthostatic tachycardia syndrome (POTS), and mast cell activation syndrome. The patient complains of dizziness, nausea, and headaches, as well as epistaxis episodes and unprovoked hives. The patients provider has recommended treatment with Gammaplex IVIG. Based on current data, the therapy that has been demonstrated to be the safest and provide the most consistent therapeutic results is IVIG. The data suggests that the widespread dysregulation of the immune system, as evidenced by mast cell activation syndrome, may be a causative factor. Overall, the beneficial effects of IVIG have been established for symptom complexes associated with the trifecta diagnoses of Ehler-Danlos Syndrome, POTS, and mast cell activation syndrome. Given these findings, the requested IVIG Gammaplex 15 grams weekly for three to six months is medically necessary for 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 reviewer is board certified in neurology with special qualification in child 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

A 39-year-old female enrollee has requested authorization and coverage of gastric bypass surgery for the treatment of morbid obesity.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested procedure is medically necessary for treatment of the patients medical condition
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested the medication combination Yervoy (ipilimumab) 300 mg and Opdivo (nivolumab) 92 mg, for three weeks, refills for one year, nine cycles for treatment of the enrollees medical condition. Findings:  Two physician reviewers found that Opdivo, Yervoy, and Keytruda are new monoclonal antibodies that bind with tumor antigens responsible for blocking immune attack from circulating lymphocytes.  The current U.S. Food and drug Administration (FDA) label for Opdivo does not state that prior treatment with Keytruda is a contraindication.  Progressive disease on Keytruda can be treated with Yervoy and Opdivo combination therapy if it has not been used before. The combination therapy is supported by the medical literature where certain patients were treated with the combination after monotherapy. That is the situation presented by this case.  Thus, there is support for the combination of Yervoy/Opdivo in this clinical setting.  The medical literature supports continued use of the medication combination every 12 weeks.  However, there is a lack of support for the requested dosing of this medication.  Final Result: Two reviewers determined that a portion of the requested medications is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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 Cialis 20 mg for treatment of his erectile dysfunction. Findings:  The physician reviewer found that erectile dysfunction is a common medical condition in men over 50 years of age, with aging being the most common etiology for vascular disease leading to erectile dysfunction. Phosphodiesterase type 5 (PDE5) inhibitors are first line therapy for treatment of erectile dysfunction.  Multiple PDE5 inhibitors are available on the market. These include Viagra, Levitra, Cialis and Stendra. They have unique pharmacokinetic profiles and side effects. This patient has been treated with Cialis since 2012 and has had an adequate response. Hence, continued treatment with Cialis is medically necessary for this patient. Final Result: The reviewers 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 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested mental health residential treatment services for treatment of her behavioral health conditions.  The Physician Reviewer found that modern psychiatric practice is aimed at treating individuals in the least restrictive setting to consolidate treatment gains and foster autonomy, harmonized relationships and mental wellness.  Due to multiple factors and unique considerations, determination of the appropriate level of care for adolescents with anxiety and depression represents a challenging endeavor.  In this patients case, the record does not substantiate the need for residential programming.  The patient was struggling with the developmental stage of identity formation which was complicated by a formidable anxiety and affective burden coupled with an underdeveloped sense of self.  During the psychological assessment the provider indicated that the patient may benefit from a therapeutic program outside of the home environment.  This treatment plan was reasonable as the patient had recently discharged from the acute level of care for the third time in five months.  The residential wilderness program appeared to adequately address this need.  According to the psychosocial assessment, the patient had been without suicidal thoughts for the two months during the wilderness program and had made therapeutic progress.  Additionally, good self-control was listed as one of her strengths.  The records do not demonstrate that the patient and family had the opportunity to capitalize on the therapeutic momentum generated by the wilderness program in the community setting.  This is important as treatment outcomes are typically optimized in the community setting.  Additionally, the medical records from the residential facility do not describe any behaviors, symptomatologies, interventions or medication management that would require treatment in a 24-hour supervised setting, while the psychiatric notes did not include an integrated summary or justification for the necessity of the placement.  All told, mental health residential treatment services were not medically indicated 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 with subspecialty certification in child and adolescent 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 seventy-one year-old female with peritoneal carcinoma, deep vein thrombosis, and pulmonary embolism is requesting a CoaguChek System for home use.Reviewers Findings:  The reviewing physician found that the submitted information provides no medical justification for a CoaguChek device.  The Health Plan denial was upheld.
Appeal type: Medical Necessity
Decision: Overturned

:  The enrollee requested coverage for the medication Entyvio. The enrollee has been diagnosed with ulcerative colitis at a young age. The patient was started on treatment with Entyvio (generic name: vedolizumab) every eight weeks and reported significant improvement. Laboratory testing of the Entyvio level in his blood was done and the report showed the level was low. A colonoscopy showed improvement in his ulcerative colitis from severe to moderate, but no resolution of ulceration and inflammation. The patient reported he still had symptoms. His physician has recommended increasing the patients dose frequency from every eight weeks to every six weeks. The medical literature has shown that dose intensification restored responsiveness in more than half of those patients and increasing dose frequency is useful if patients are not responding sufficiently to an eight-week dosing interval.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a 57-year-old male with hepatitis C and depression. In light of the patients depression and the potential side effects of interferon, the patients provider has recommended monotherapy with ribavirin. The Health Plan has denied coverage for the requested medication on the basis it is not medically necessary for treatment of the patients condition.The use of ribavirin as a monotherapy is not medically indicated or necessary. The submitted information includes two pilot studies and four randomized double-blind placebo studies on ribavirin as a monotherapy. In general, the results indicated that the use of this drug alone for 6-12 months did not result in a sustained biochemical response and ALT levels returned to baseline within 2-3 months after discontinuing the drug. No virus was cleared and no improvement in liver biopsy was noted. Thus, the data suggests ribavirin is not beneficial as a short course therapy. A longer course of ribavirin therapy has not yet been appropriately studied. In summary, the use of ribavirin as monotherapy in patients with hepatitis C is not the standard of care and there are insufficient data to support its use in this patient. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Rituxan for treatment of his medical condition. Findings:  The physician reviewer found that the patient is currently receiving treatment for the conditions of systemic lupus erythematosus and retroperitoneal fibrosis.  The available medical records do not document clear provider rationale for treatment with Rituxan.  The requested medication Rituxan has been approved for the treatment of rheumatoid arthritis, vasculitis (Wegeners granulomatosis and microscopic polyangiitis), lymphoma and leukemia.  The available medical records do not document the presence of any of these diagnoses.  All told, Rituxan is not medically indicated 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 rheumatology 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 hepatitis C.  Two physician reviewers found that there is sufficient support for the requested medication in this clinical setting.  Per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  The medical evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The requested medication is medically necessary to prevent further progression of fibrosis due to ongoing hepatitis C infection and prevent potential complications of advanced liver disease.  All told, Harvoni is medically indicated for the treatment of this patient.  Final Result:  Two reviewers determined that that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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

A 48-year-old male enrollee has requested the medication Byetta for treatment of his type 2 diabetes mellitus. Findings:  The physician reviewer found that Byetta is presently indicated as adjunctive therapy to improve glycemic control in patients with diabetes mellitus type 2 who are taking metformin or sulfonylureas, alone or in combination, but have not achieved adequate control. Adequate control is defined as a hemoglobin A1c of less than 6.5%. Patients who are not well controlled on oral agents generally progress to insulin therapy. Byetta, which is at least as effective as insulin in improving blood sugar control, may have an advantage in patients such as this man. Treatment with Byetta is associated with weight loss as opposed to insulin, where treatment frequently causes further weight gain. The patient was not well controlled on metformin and insulin. When Byetta was added to these agents, his blood sugars improved.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 50-year-old female who has a history of painful intercourse and urinary tract symptoms. She has been treated for pelvic floor myofascial trigger points and has had manual therapy of the pelvic floor. She is seeking authorization for continued therapy. The Health Plan has denied this request.The patient appears to have problems with intercourse and lower pelvic discomfort that affects the vulva, vagina, and bladder. Based upon the information provided, it appears there is a possibility the patient may have diagnoses of vaginismus, interstitial cystitis, dyspareunia, and vulvodynia. Therefore, further multispecialty (urology, gynecology) evaluation and workup is necessary to attempt to confirm the above diagnoses. Furthermore, based upon the patients condition, the pelvic floor therapy she has been receiving is not an effective long-term therapy. In addition, the records submitted demonstrate her condition has stabilized and has not improved with continued therapy.Based upon the information set forth above, I have determined the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a 15-year-old male enrollee requested subtalar arthroereisis surgery for medical treatment of the enrollees foot deformity. Findings:  Two physician reviewers found that the current peer-reviewed medical literature does not support the clinical effectiveness and safety of subtalar arthroereisis in this clinical setting. The procedure has limited potential for substantial improvement in pediatric patients with symptomatic flatfoot (Jay and Din). In addition, this patients history and physical findings do not document exhaustion of conservative therapies. All told, the available scientific data does not demonstrate subtalar arthroereisis is 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 Qualitest brand hydrocodone/acetaminophen (Norco) 10/325 mg, 10 per day (300 per month).The patient has a long-standing history of chronic pain and has been on 10 Norco tablets daily to manage her pain for the past six years. She has x-ray proven osteoarthritis of her hands and feet, but the work up for connective tissue disease by her PCP was negative. Her Rheumatologist has advised her to follow up with her PCP and Pain Management. Her PCP has expressed concern regarding the quantity of tablets being used daily and offered a conservative tapering plan of her medications beginning with an allowance of 8.5 tablets daily with a decrease of one-half tablets per month in conjunction with Pain Management treatment. The patient has declined this offer and is requesting 10 tablets daily of Qualitest brand hydrocodone/acetaminophen only. The most recent European best practices guidelines from 2017 clearly state that chronic opioid therapy is not indicated for fibromyalgia, and this recommendation came with a strong consensus. Furthermore, the consumption of 10 Norco tablets daily carries with it a significant acetaminophen burden of over 3000 mg a day. The current best practices guidelines recommend that patients keep their daily acetaminophen consumption to under 2000 mg a day. Accordingly, the requested Qualitest brand hydrocodone/acetaminophen (Norco) 10/325 mg, quantity of 10 per day (300 per month), is not medically necessary to treat 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 anesthesiology, with subspecialty 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 Adderall extended release for treatment of the enrollees autism spectrum disorder, anxiety, and attention deficit/hyperactivity disorder (ADHD). Findings: The physician reviewer found that as noted in the medical literature, ADHD is a common developmental disorder. According to the American Academy of Child and Adolescent Psychiatry, up to 65% of children with ADHD will continue to have impairing symptoms into adulthood, and the condition commonly co-occurs with autism spectrum disorder. Per the American Psychiatric Association (APA), stimulants such as methylphenidate and amphetamine salts are the two major categories of pharmacological treatment for ADHD and are considered the first-line medication treatments for the disorder. The clinical effect of these medications is generated by neurotransmitter enhancement in the prefrontal cortex of the brain. Adderall XR is a psychostimulant medication composed of 50% immediate-release beads and 50% delayed-release beads designed to mimic the effects of two doses of immediate release Adderall given four hours apart. Adderall does not serve critical psychiatric functions such as treating depression, bipolarity, suicidality, aggression, anxiety, substance use, or psychosis. Adderall is a potent medication, which means it has the potential for abuse and can worsen anxiety. Further, Adderall is a positive ionotrope, which means it can make the heart pump harder and faster. In this case, there is evidence that the stimulant is contributing to hypertension and tachycardia. As such, a dose reduction is safe, appropriate and consistent with good medical practice. The patients provider offered a meeting to discuss an alternative medication, atomoxetine, which is approved by the United States Food and Drug Administration (FDA) for adult ADHD. Further, the patient has consulted with another provider for a second opinion. The risk of continued Adderall therapy at 40 mg daily outweighs the benefit considering the cardiovascular sequelae coupled with the availability of standard alternatives and reasonable access to specialty services. All told, the requested Adderall XR 40 mg 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 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.