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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Ambien 5 mg oral tablets. The U.S. Food and Drug Administration (FDA) has approved the use of Ambien for the short-term treatment of insomnia. Ambien is not approved for the long-term treatment of insomnia. When treating insomnia, patients should receive therapy for any medical condition, psychiatric illness, substance abuse, or sleep disorder that may be precipitating or exacerbating the insomnia. For patients who continue to have insomnia that is severe enough to require intervention, cognitive behavioral therapy (CBT) is the initial therapy that is recommended. If a patient requires a combination of behavioral therapy and medication, a short-acting medication is recommended for six to eight weeks and then tapered. If the patient is still having symptoms, an evaluation in a sleep disorder center may be indicated prior to the institution of long-term medications.  In this case, the documentation does not support that the patient has received optimal therapy for medical and psychiatric conditions or that non-pharmacologic treatment for insomnia has failed. Furthermore, the patient was noted to have been taking approximately 85 mg of Ambien per day, which exceeds the recommended maximum daily dosage. Therefore, Ambien 5 mg oral tablets are 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for prostatic urethral lift implant (Urolift) for treatment of the enrollee who has a history of enlarged prostate with lower urinary tract symptoms, chronic prostatitis and benign prostatic hyperplasia (BPH). Findings:  The 3 physician reviewers found that the patient is a male who presented to his provider with a history of lower urinary tract symptoms. He was diagnosed with benign prostatic hyperplasia (BPH). The patient was prescribed finasteride and Rapaflo to improve his symptoms. However, the patient reported that the medications have provided some relief but his symptoms still persist. The patient has requested authorization and coverage for prostatic urethral lift implant (Urolift). The Health Plan denied the requested procedure. The Health Plan stated that the requested procedure is investigational for the treatment of this patients medical condition.The prostatic urethral lift (Urolift) system is a novel, minimally invasive approach to treating BPH that lifts or holds the enlarged prostate tissue out of the way so it no longer blocks the urethra. Recent clinical trials including prospective sham-controlled randomized studies have shown that the Urolift system is safe and effective in relieving lower urinary tract symptoms due to BPH without significantly compromising sexual function.  Maintained outcomes have been reported at 24-month follow-up. Compared with transurethral resection of the prostate (TURP) and laser photoselective vaporization of the prostate (PVP), the Urolift system is a minimally invasive procedure without a requirement of general anesthesia and with a potentially shorter operative time. In light of recent studies documenting the clinical effectiveness of this procedure, as well as the support of this procedure by organizations such as the American Urological Association, the use of the Urolift is clinically appropriate in this patients case. All told, the requested Urolift procedure is likely to be more beneficial for treatment of this patients BPH than any available standard therapy. Final Result: The 3 reviewers determined that the requested procedure 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 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

A 51-year-old female requested authorization and coverage for breast reduction surgery. The health plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees ptotic breasts.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Epclusa 400-100 mg tablets for 12 weeks. Findings:  The physician reviewer found that According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines do not comment on the treatment of genotype 6 hepatitis C after failure of a direct-acting antiviral agent but reference re-treatment after peg-interferon and ribavirin failures only. The guidelines recommend 24 weeks of Epclusa and the use of ribavirin in patients with genotypes 1 or 3 who have failed an nonstructural protein 5A (NS5A) inhibitor such as Harvoni or Daklinza, based on clinical trial data. Additionally, guidelines issued by the European Association for the Study of the Liver (EASL) state that after failure of an NS5A inhibitor, such as Harvoni, re-treatment of genotype 6 patients should be performed with Epclusa and ribavirin for 24 weeks, which is not the regimen requested in this case. The ASTRAL-1 trial does not lend support to the requested treatment, as it did not include any genotype 6 patients who failed an NS5A inhibitor and then were re-treated with Epclusa . For these reasons, the requested treatment with Epclusa to be used with ribavirin for 12 weeks is not supported as medically necessary for the re-treatment of this patients hepatitis C infection. 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: Upheld

A 64-year-old male enrollee has requested for traditional physical therapy and occupational therapy for treatment of the enrollees his status post stroke. Findings:  The physician reviewer found that it is not expected that further skilled physical therapy would change this outcome at this late date following his stroke. Studies to date involving chronic stroke rehabilitation have consisted of small trials with outcomes focused on mobility. Of the studies that have been performed involving upper extremity function, improvement has remained minimal this far out from the seminal event except under unusual and experimental conditions that have not been confirmed with adequate trials (Koganemaru, et al.). Therefore, the requested physical therapy is not medically necessary for treatment of this patients post stroke sequelae. The requested occupational therapy does not have an expectation for practical further improvement and is not medically necessary for this patient. He is independent with grooming, transfers, bathing, and dressing.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested the medication Fentora for the treatment of her brachial plexopathy.    Findings:  The physician reviewer found that Fentora is approved by the Food and Drug Administration for use in cancer pain patients.  The original package insert specifically states that its use is to be limited to cancer pain.  There are several case series and individual case reports in the literature, but no randomized controlled trials of this medication in non-malignant pain patients. Fentoras effectiveness in nonmalignant pain is unproven. It is noted that there are agents (OxyIR and OxyFast) that are on the Health Plans formulary, but are not specifically listed as having been tried in this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 36-year-old male enrollee requested authorization and coverage of continued occupational and physical therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for the enrollees rehabilitation after a stroke.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 51-year-old female enrollee has requested Botox injections for treatment of the enrollees migraine headaches. Findings:  Three physician reviewers found that although Botox should not be selected as a first-line headache therapy there is adequate literature supporting its use for patients who are refractory to standard treatment. In this particular case, the patient has failed previous first-line therapies thus warranting a trial of Botox. A repeat assessment would be reasonable after 12-16 months to ensure that the Botox has been beneficial and to assess whether long-term treatment should be considered. For these reasons, the requested treatment with Botox should not be deemed investigational in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Supartz injections for treatment of the enrollees right knee osteoarthritis. Findings:  The physician reviewer found that  There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Maheu and colleagues conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. All told, the requested Supartz injections are supported as medically necessary for treatment of this patients knee osteoarthritis. Final Result: The reviewer determined that the requested service 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 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: Experimental/Investigational
Decision: Overturned

A 65-year-old female enrollee has requested Alimta (pemetrexed) for the treatment of her ovarian cancer.  Findings:  Two physician reviewers found that patients with chemotherapy-resistant ovarian cancer rarely experience a clinical response with any of the known drugs used for treatment of this disease. This is especially true with the administration of seven chemotherapy regimens as was described in regard to this patient. However, she was able to achieve a clinical response with the administration of Alimta in combination with Tarceva. The fact that the patient progressed on Tarceva alone would indicate that Alimta was the active agent in this combination. The FDA granted approval for the use of Alimta in mesothelioma and lung cancer, giving some assurance of safety.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lyrica 50 mg. In the medical literature recently conducted a review of Lyrica for neuropathic pain in adults concluded that studies showed limited evidence of benefit in neuropathic back pain or sciatica, neuropathic cancer pain, or polyneuropathy. In addition, the North American Spine Society (NASS) guidelines concluded that there is insufficient evidence to make a recommendation for or against the use of gabapentin in the treatment of lumbar disc herniation with radiculopathy. In this case, the patient has reported low back pain with radiation into the right lower extremity consistent with the diagnosis of sciatica. A lumbar magnetic resonance imaging (MRI) revealed L5-S1 degenerative disc disease with partial right lateral recess stenosis which correlates with her clinical symptoms. She has tried and failed physical therapy due to pain. The providers notes state that her treatment has consisted of medication management with Lyrica, Naproxen, Percocet, Norco, Lidoderm patches, tizanidine and gabapentin. The providers notes do not state that the patient has tried and failed neuropathic agents from other drug classes including anticonvulsants and tricyclic acid medications. The patient reports that in early 2018 she was started on Lyrica 50 mg three times a day and found this to be helpful in managing her sciatic pain. However, based on the current medical literature, there is limited evidence to support the use of Lyrica for the treatment of sciatic pain. Accordingly, the requested Lyrica 50 mg 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 anesthesiology with subspecialty certification in pain management 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings: Two physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient presents with breast tissue that have been described as being very dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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. The 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an ultra-lightweight manual wheelchair and accessories.In this case, the records do not establish that the patient has the physical capacity to self-propel a manual wheelchair safely and effectively, or to perform pressure relief without power tilt-in-space functionality. This is consistent with the patients current need, as a person with a C6-7 level spinal cord injury, residual tetraplegia and prior history of coccygeal pressure ulcer, for a power wheelchair with tilt-in-space as his primary mobility device. There is no documented, detailed physical examination and functional evaluation related to his hand function to establish that he is an appropriate ultralight weight manual wheelchair user. There is also no documented, pertinent, detailed physical examination and functional evaluation related to his ability to perform effective, reliable and consistent pressure relieving and repositioning maneuvers using his own body power, which is critical to mitigate pressure injury risk, as well as to address posture/positioning for comfort and fatigue management. The patient, notably, is reported to be obese, which would make independent pressure relieving and repositioning maneuvers more challenging. The patients primary means of mobility is reported to be his power wheelchair. The patient has or should have a device that is reliable enough to provide his mobility needs on a daily basis. In the event that the patients power wheelchair breaks down or becomes non-operational, an equivalent, loaner power wheelchair should be provided by the durable medical equipment vendor until the primary wheelchair is fixed. If the patients power wheelchair is frequently non-operational (i.e., defective), it should be replaced altogether by the durable medical equipment vendor with a new device that works reliably. If non-operational power wheelchairs are a consistent problem, a different vendor should be considered. Under these circumstances, the requested ultra-light weight manual wheelchair and accessories are not medically necessary to treat the patients condition (C6-C7 spinal cord injury with paraplegia).Final Result: The reviewer determined that the requested durable medical equipment is not medically necessary to treat the patients condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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 advanced lipoprotein testing for evaluation of the enrollees hypercholesterolemia.  Findings: Two physician reviewers found that the superior efficacy of the services at issue has not been established.  This patient had an increased risk of coronary vascular disease.  In this circumstance, primary prevention guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees, and are endorsed by several national organizations.  These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein, high-density lipoprotein subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  All told, advanced lipoprotein testing is not likely to have been of greater benefit than other methods of evaluating this patient.Final Result: Two reviewers determined that the services at issue is 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 physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections. Findings:  Two of the three physician reviewers found that there is sufficient support for the requested services in this clinical setting. The records document pelvic pain, muscle spasm, pelvic floor dysfunction and vulvar vestibulitis. This patient has continued to experience symptoms despite treatment with physical therapy, Valium suppositories and trigger point injections. The records document chronic pelvic pain which has not improved with the standard course of treatment. The medical literature supports Botox injections as the next step in this clinical setting. Therefore, the requested Botox injections are likely to be more efficacious than other treatment options. Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology and are actively practicing. The 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.