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

The representative of a 21-year-old female enrollee requested authorization and coverage of residential eating disorder treatment. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees eating disorder.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested services are medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested anesthesia services for treatment of his medical condition.   Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the services at issue. Colonoscopy may be safely and effectively performed with conscious sedation of a benzodiazepine alone or with a narcotic in an office-based setting and without the need of monitored anesthesia care with propofol. McQuaid and Laine performed a systematic review of randomized controlled trials to compare efficacy, safety, and efficiency of agents used for moderate sedation in esophagogastroduodenoscopy (EGD) or colonoscopy. The authors concluded that moderate sedation provides a high level of physician and patient satisfaction and low risk of serious adverse events with all currently available agents. Midazolam-based regimens have longer sedation and recovery times than propofol. In this case, the anesthesia services were not medically necessary. The patient did not present with a significant history that would require monitored anesthesia care. Moreover, the standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and co-morbid conditions that would put the patient at risk during the procedure. There is no documentation of co-morbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care. Given the above, 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 anesthesiology with sub-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: Overturned

A 54-year-old female enrollee has requested outpatient psychotherapy at a frequency of two times per week for treatment of her major depressive disorder, panic disorder and eating disorder.  Findings:  The physician reviewer found that twice weekly outpatient psychotherapy from the date in question forward was not and is not medically necessary. The submitted documentation does not demonstrate the patients symptoms were at a severity level that required continued twice weekly sessions as of the said date. Although a risk assessment is not documented in the records provided, the progress notes do not reflect concern about the potential for suicide or decompensation. There is no evidence that the patient has been hospitalized in the past or was at risk for a higher level of care. American Psychiatric Association practice guidelines indicate that patients with panic disorder as well as major depression should be managed in the least intensive setting which is likely to be safe and effective. Based upon the submitted documentation, the patient could have been safely and effectively managed in the context of once weekly sessions as of the date in question. With regard to the medical necessity of twice weekly outpatient psychotherapy sessions going forward, transition to once a week sessions is medically appropriate at this time. Goals and time frames should be established with progress toward goals documented.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 44-year-old female with refractory migraine and has been treated with several preventative regimens without sufficient success. She is currently on combination therapy with Lyrica as a preventative and Zomig and Amerge as abortive medications. The patient apparently requires daily to near daily therapy with one of the triptans to adequately manage her headaches.  The Health Plan has denied authorization for 36 Amerge tablets per month based upon their determination that more than 18 tablets per month is not medically necessary.The patient has migraine headaches and has been managed with preventative and acute therapies. Although daily triptan use has the potential for inducing rebound or medication-overuse headaches, several clinical trials have found them safe for daily use.  Transitional therapy with a triptan on a daily basis is a logical approach while awaiting response from a preventative that may take some time to show a benefit.  The higher quantity of Amerge tablets should be approved for an interval of 2-3 months to allow for titration and reassessment of the patients preventative regimen.  Patient follow-up is essential with a review of her headache diary, the tolerability of the regimen, her compliance, and her successes and failures in managing her migraines.Based upon the information set forth above, I have determined the requested prescription is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a spinal cord stimulator. The submitted documentation fails to demonstrate the medical necessity of the requested device. In an application for independent medical review, the patient reported that she has been diagnosed with complex regional pain syndrome. However, the notes submitted do not support the diagnosis of complex regional pain syndrome. The records do not include a physician generated history and physical examination supporting this diagnosis. There is no documentation of a diagnostic work-up performed or of past therapies trialed. The medical evidence does not support the requested device in this setting. Therefore, the requested spinal cord stimulator is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested device 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 sub-specialty 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: Experimental/Investigational
Decision: Upheld

A 29-year-old female enrollee has requested for radiofrequency neurotomy of the cervical spine for treatment of her post-herpetic occipital neuralgia. Findings:  Two physician reviewers found that there is not sufficient evidence in the scientific literature to show that the procedure is effective in the long-term. More peer-reviewed outcomes data is needed to establish the safety and efficacy of this procedure in the long-term.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for water assisted liposuction of the arms, thighs, abdomen and buttocks. Researchers describe lipedema as a disorder characterized by localized adiposity of the lower extremities extending from hips to ankles, often occurring in females with a family history of the condition, and typically unresponsive to weight loss. The authors note that in addition to aesthetic deformity, the disease may cause pain in the lower extremities, particularly with pressure, as well as easy bruising. Researchers conclude that lymph-sparing liposuction using tumescent local anesthesia is currently the only effective treatment for lipedema. In this case, the patient has a diagnosis of lipedema. Visit notes reported that the patient underwent lymph-sparing lipectomy procedures for treatment of the legs, arms, abdomen, and buttocks approximately two years prior, but that she reported that swelling and pain had returned. She rated her pain as an eight or nine out ten on an average day, and at ten out of ten on bad days. A physical examination reported tender fat and nodules in the upper gluteal area, upper arms, forearms, abdomen, hips, thighs, knees, and lower legs. Undated photographs of the patient showed significant fatty fullness in the thighs and lower legs with some cuffing is present at the ankles. Given the patients diagnosis of lipedema and recurrence of symptoms, tumescent liposuction is considered standard of care. Therefore, water assisted liposuction of the arms, thighs, abdomen and buttocks is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested water assisted liposuction of the arms, thighs, abdomen and buttocks is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service 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: Physician reviewer 1 is board certified in plastic surgery and is actively practicing. Physician reviewer 2 is board certified in plastic surgery with sub-specialty certification in surgery of the hand and is actively practicing. Physician reviewer 3 is board certified in plastic surgery and is 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for eight weeks for treatment of her hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, Harvoni is first-line therapy for treatment-naive genotype 1 patients. Non-cirrhotic patients with viral load below 6,000,000 IU/mL can be treated with Harvoni for eight weeks.  These guideline recommendations are based on multiple randomized clinical trials.  All told, the requested Harvoni for eight weeks is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The 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 Harvoni for 12 weeks for treatment of his hepatitis C.  Findings:  Three physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy less than 12 months due to non-liver-related conditions.  Patients with cirrhosis are considered highest priority for therapy.  This patient should be considered treatment-naive, as the only therapy attempted in the past was interferon monotherapy for one week.  In cirrhotic treatment-naive patients with hepatitis C, genotype 1 infection, therapy with Harvoni for 12 weeks is recommended.  Therefore, the requested Harvoni for 12 weeks is medically indicated for the treatment of this patient.   Final Result: Three 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 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 male enrollee requested Humira for medical treatment of his plaque psoriasis.  Findings:  The physician reviewer found that Humira is a fully human tumor necrosis factor (TNF)-alpha monoclonal antibody approved for the treatment of rheumatoid arthritis which is also used in treating other conditions, including psoriasis and psoriatic arthritis (Scheinfeld). Humira has been shown to treat moderate to severe chronic plaque psoriasis and psoriatic arthritis (Croom and McCormack). Moreover, this patients provider noted that the patient is unable to visit his provider three times per week for UV light therapy treatments. Thus, treatment of this patient with Humira is supported as medically necessary as recommended by the patients provider.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old male enrollee requested authorization and coverage of a custom fit ACL brace due to the high risk of re-injury following arthroscopy and ACL debridement.  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 equipment is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Ultram (tramadol) tablets (50 mg by mouth four times a day as needed). At issue is whether the requested Ultram (tramadol) tablets (50 mg by mouth four times a day as needed) is medically necessary for treatment of this patient. The Centers for Disease Control and Prevention (CDC) guidelines state that, nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient (Dowell, et al.). The CDC noted that, Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. The Federation of State Medical Boards (FSMB) guidelines recommend opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. and maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met. The FSMB state that, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. In this case, the patient has chronic knee pain due to advanced osteoarthritis. However, the records document that the patient was combining benzodiazepines with alcohol, which prompted one of the providers to discontinue benzodiazepine therapy and refer the patient to addiction medicine. The patients orthopedic specialist has advised against opioid therapy and suggested treatment with NSAIDs along with steroid injections in the knee, and possible  future joint replacement. Overall, the records indicate that the risk-to-benefit ratio is unfavorable and that the patient is not considered an ideal candidate for chronic opioid therapy. Given these findings, the requested Ultram (tramadol) tablets (50 mg by mouth four times a day as needed) is 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old male enrollee requested authorization and coverage of intradiscal electrothermal therapy (IDET). The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees back pain.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested procedure is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne testing. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of metastatic lung cancer.Findings:  The therapy for advanced non-small cell adenocarcinoma has been revolutionized by the finding of EGFR mutations in adenocarcinomas, especially in this patient who is a non-smoker. The medical literature indicates that even if stage IV disease is present, therapy targeted to EGFR with erlotinib results in prolonged survival when compared with standard chemotherapy regimens. The mutational landscape of non-small cell lung cancer (NSCLC) has significantly expanded in the past two to three years to encompass gain of function in multiple oncogenes with major prognostic and therapeutic consequences. It is generally accepted that the panel of mutations typically analyzed in NSCLC are mutually exclusive somatic driver mutations. Generally, KRAS, TP53, and BRAF are included in these panels and are informative. KRAS and EGFR mutations are usually mutually exclusive so a sample with KRAS mutation does not need to be further analyzed for EGFR mutation. KRAS mutation may confer a poor prognosis on patients with wild type EGFR sequence treated with erlotinib as second line therapy. In this case, the patients tumor tested negative for this panel. Patients on targeted therapy do develop resistance to erlotinib and this too may be appreciated at the genetic level by recognition of new mutations or amplifications in parallel signal transduction pathways. BRAF mutations may suggest alternative targeted therapies that may be better than those selected empirically. Accordingly, current medical evidence supports the superior efficacy of the services at issue in this patients case. For these reasons, FoundationOne testing was likely to have been more effective than the standard methods for evaluating this patients medical condition.Final Result: Two of the three reviewers have determined that the services at issue were likely to be more beneficial for evaluation of your medical condition than any available standard therapy.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: Urgent Care
Decision: Overturned

A 64-year-old male enrollee has requested reimbursement for services provided on an emergent basis. Findings:  The physician reviewer found that the patient is a 64-year-old male who underwent urgent/emergent evaluation, resuscitation and bladder tumor resection and fulguration. The pathology specimen showed high grade transitional cell carcinoma and although the operative report states resection was carried out through to the perivesical fat, no muscle was found on pathology to assess the depth of tumor penetration for accurate staging and planning of treatment options. The patient underwent an out-of-network resection six weeks later on the date in question and was found to have no muscle invasion. He is seeking coverage for the out-of-network procedure on the grounds that it was required on an emergent basis. At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date in question. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.The patients situation on the date in question met prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would reasonably expect the absence of immediate treatment to jeopardize his or her health. In the face of a high grade bladder tumor on biopsy and failure to obtain muscle samples in the area of the tumor, repeat resection was appropriate within six weeks of the original procedure. The patients family states that they had been informed that a repeat biopsy could not be performed by an in-network provider for more than two to three months. A prudent layperson in this situation would reasonably believe that a delay of potentially several months would place his or her health in serious jeopardy. Furthermore, the peer-reviewed literature supports the benefit and need for resection in a timely manner in this clinical setting.