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

A 60-year-old male enrollee has requested Concerta 36mg, twice daily for treatment of his attention deficit/hyperactivity disorder.  Findings:  The physician reviewer found that stimulant medication is the gold standard psychopharmacologic intervention for attention deficit/hyperactivity disorder.  Accordingly, Concerta 72mg daily may be an appropriate dose for the treatment of uncomplicated attention deficit/hyperactivity disorder.  However, it is not medically necessary in this patients case due to diagnostic uncertainty and evidence of misuse.  Per the submitted records, this patient has a history of unilateral dose escalation, losing his medication, and early refill requests.  Diagnostically, this patient has a history of treatment with antipsychotic medication, suggestive of a co-occurring formal thought disorder or other serious mental disorder.  The patient was noted to be psychotic, and the medication was stopped.  Continued stimulant treatment with this diagnostic uncertainty and unclear clinical status would be inconsistent with good medical practice.  All told, Concerta 36mg, twice daily, is not medically indicated in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned

A 47-year-old female enrollee has requested for sleeve gastrectomy for treatment of her morbid obesity.   Findings:  Three physician reviewers found that the patient meets the criteria set by the National Institutes of Health (NIH) for weight loss surgery. There is mounting published evidence that the sleeve gastrectomy is an acceptable surgical option. The patient has an irreversible liver condition. Sleeve gastrectomy avoids the anatomy of the hepatic region and will cause less liver stress than any other operation.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for celiac plexus block and two related office outpatient visits are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  The physician reviewer found that Ehlers-Danlos can be a debilitating disease with chronic pain in the joints and abdomen. The treatment of chronic abdominal pain in the setting of Ehlers-Danlos remains difficult. Thus, opioid sparing techniques, such as celiac plexus blocks, need to be considered early in the treatment algorithm even in cases of non-malignant chronic abdominal pain. Barbon and colleagues reported that celiac plexus blocks provided decreased pain in patients with Ehlers-Danlos syndrome and medial arcuate ligament syndrome. Given this support, the requested celiac plexus block and two related office outpatient visits are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested celiac plexus block and two related office outpatient visits are 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 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 anesthesiology with subspecialty certification in pain management 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: Upheld

The patient is a 43-year-old female who underwent laparoscopic cholecystectomy in September 2004. Thereafter, the patient began experiencing abdominal pain and noticed an increasing bulge in the lower abdomen near the umbilicus. In April 2005, the patient underwent ventral hernia repair. Notes from May 2005 indicate the patients wounds were well healed. A postoperative seroma was aspirated and sent for gram and stain culture. The gram stain showed no white cells and the results of the culture were not provided. The patient is now requesting a full body scan.There is no justification for a full body scan in this case. An abdominal and pelvic CT scan may be indicated but only after further evaluation by the patients surgeon. The results of the seroma culture and physical findings will determine whether a CT scan is necessary. There is no evidence to support the need for a full body scan; if necessary the patient can be appropriately evaluated by CT scanning. Therefore, I have determined the requested full body scan is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee requested authorization and coverage of a gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.Three physician reviewers performed a medical necessity Independent Medical Review. Two physician reviewers concluded that the requested procedure is not likely medically necessary for treatment of the enrollee's medical condition. One physician reviewer concluded that the requested procedure is medically necessary for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested procedure is not medically necessary for treatment of your medical condition, the Health Plans denial has been upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested reimbursement for a wearable cardiac defibrillator LifeVest.  In this circumstance, there was potential for recovery of left ventricular function over time with medical therapy and there was no documented indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, unexplained syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until at least 90 days have elapsed with continued left ventricular dysfunction demonstrated by an ejection fraction less than 35% despite appropriate treatment. A prophylactic defibrillator before this time has not been demonstrated to improve outcome. At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed or required explantation. For these reasons, the wearable cardiac defibrillator LifeVest was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Two of the three physician reviewers found the wearable cardiac defibrillator LifeVest was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty 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 gene testing (Uveal melanoma) for evaluation of his medical condition.  Findings:  Three physician reviewers found that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. There is sufficient support in the peer-reviewed literature demonstrating that this testing is more beneficial than standard therapy. Genetic testing of uveal melanoma tissue has proven useful in determining potential for metastasis, and guiding treatment for uveal melanoma. For the reasons stated above, the requested gene testing (Uveal melanoma) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three 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 reviewers are board certified in ophthalmology and are 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 authorization and coverage for cervical artificial disc replacement, single level. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees cervical pain.Findings: There is sufficient support in the medical literature for the requested services in this clinical setting. Cervical total disc replacement at one or two levels, anterior cervical discectomy and fusion, as well as hybrid surgery with a combination of the two, significantly improve general and disease specific measures compared with baseline. There are significant benefits documented in the literature with respect to total disc replacement, which results in improved general and disease specific outcome measures and a lower rate of reoperation in the two level disc replacement or hybrid patients versus two level anterior cervical discectomy and fusion control patients. Recent medical literature with regards to the long term results of cervical total disc replacement including one and two level and hybrid surgery, such as in this patients case, find significant benefits over the conventional multi-level anterior cervical discectomy and fusion. The literature indicates that there is motion preservation, decreased incidence of adjacent segment disease, and improved clinical outcome as well as decreased need for revision surgery. Therefore, the medical necessity for the requested cervical artificial disc replacement, single level has been demonstrated in this patients case. Final Result: The reviewer determined that requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for PuraPly AM Wound Matrix applied during Mohs surgery. Treatment of basal cell carcinoma on the face can be safely and effectively performed by Mohs micrographic surgery. Repair of the defect can be accomplished through several means including secondary intention or primary intention including flaps or grafts. In this patients case, the size and location of the defect did not prevent either a flap or a graft from a donor skin site. The records do not document a clinical indication for PuraPly over an alternate option such as a flap or graft, which have been demonstrated to provide adequate cosmesis and functionality. The current peer-reviewed medical literature does not support use of skin substitutes such as PuraPly AM Wound Matrix for Mohs surgery (Lu, et al.). Thus, the PuraPly AM Wound Matrix applied during Mohs surgery was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Two of the three physician reviewers found the PuraPly AM Wound Matrix applied during Mohs surgery was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in dermatology and is actively practicing. Physician reviewer 2 is board certified in dermatology and is actively practicing. Physician reviewer 3 is board certified in dermatology 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: The patient has requested authorization and coverage for Linzess 290 mcg capsule. Love and colleagues noted that Linzess has a novel mechanism of action, resulting in accelerated intestinal transit and is indicated for treatment of chronic constipation. Furnari and colleagues noted that linaclotide may be recommended for step-up management of chronic constibation. Lembo and colleagues reported that linaclotide therapy was associated with few adverse events and produced rapid and sustained improvement of bowel habits, abdominal symptoms, global relief, and quality of life in patients with chronic constipation. In this case, the patient has tried and failed Miralax and diet modifications to treat her chronic constipation. In this clinical setting, the requested medication is medically indicated. Therefore, Linzess 290 mcg capsule is medically necessary 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 treatment of his 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. The guidelines classify patients with cirrhosis as high priority for treatment.  The guidelines recommend that cirrhotic patients who have failed therapy with Sovaldi and Olysio should be treated with Harvoni and ribavirin for 24 weeks.  The requested medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. For these reasons, 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: Overturned

The enrollee is requesting authorization and coverage for Anakinra (Kineret). The enrollee has an auto-inflammatory disorder, not otherwise specified, that includes symptoms of recurring fevers, swollen lymph nodes, nausea and vomiting. She began anakinra and the enrollee reports the anakinra has helped her symptoms significantly because she has experienced fewer disease flares, what flares she does experience are less severe, and she can continue to participate in school and work when experiencing a flare; which had not been possible in the past. The auto-inflammatory disorders are a rare family of disorders; usually starting in childhood. This enrollee is now an adult. Large trials of treatment are not available for most auto-inflammatory disorders. Anakinra is approved for one of these, cryopyrin-associated auto-inflammatory syndromes. It is used in many of the other auto-inflammatory disorders as well. Literature reports effective therapies are available for many of the syndromes, including colchicine, interleukin 1 blockade, and anti-tumor necrosis factor therapies. Interleukin 1 blockers, such as anakinra, are recognized as effective treatments for auto-inflammatory disorders, and the enrollee should be continued on it.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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old male enrollee has requested Byetta for the treatment of his diabetes. Findings:  The physician reviewer found that Byetta is a GLP-1 agonist and Januvia is a DPP-IV inhibitor that will decrease the downgrade of GLP-1, an incretin that stimulates insulin production in relation to a meal. There is a lack of studies to support the safety of their use at the same time and long-term.  In addition, the combined use would be duplication of therapeutic action as they both potentiate the incretin effect. Byetta was not and is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Infed iron infusion therapy. Despite long-term oral iron therapy, this patient has been unable to replete her iron stores. This may possibly be due to gastritis. Regardless of the presence of symptoms, all patients with iron deficiency anemia and most patients with iron deficiency without anemia require treatment. Although oral iron is the initial treatment approach for iron deficiency anemia, some patients fail to respond to or cannot tolerate oral iron. For these patients, there is an indication for intravenous iron to replenish iron stores. This patient has been treated with oral iron, yet her iron stores remain depleted based on recent laboratory results. Therefore, the requested Infed iron infusion therapy 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 internal medicine with subspecialty certifications in medical oncology and hematology 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 62-year-old male enrollee has requested a full body PET scan for evaluation of his stage IV renal cell carcinoma. Findings:  Two physician reviewers found that the American College of Radiology notes that PET scanning may be helpful for establishing metastatic disease in lesions detected by MRI, CT or bone scan. Additionally, PET scan may be used to detect unsuspected metastases in high-risk patients. This patient is undergoing relatively toxic therapy, and he is being considered for ablation. PET scanning was initially used to establish the diagnosis and extent of disease.  At this time, it is medically reasonable to evaluate the response to treatment in order to determine treatment options, especially since the patient is experiencing toxicity to Sutent. A PET scan will provide structural information and establish metabolic activity of the disease. In this patients case, the requested full body PET scan is likely to be superior over other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld

A 67-year-old female enrollee requested an Euflexxa injection for medical treatment of her rheumatoid arthritis and osteoarthritis. Findings:  The physician reviewer found that there is a lack of evidence from the documentation provided that the patient has primary osteoarthritis of the knee. The uniform joint space narrowing and lack of bone reaction suggest that rheumatoid arthritis is the primary cause of her progressive knee arthritis, and this has been properly treated with intra-articular steroid injections and DMARD therapy. Further, there is no role for hyaluronic acid injections for patients with inflammatory arthritis. A recent meta-analysis by Rutjes and colleagues revealed that these agents are associated with a clinically irrelevant benefit and had an adverse safety profile. The most recent treatment guideline from the American Academy of Orthopedic Surgery (AAOS) does not support the use of viscosupplementation for the treatment of osteoarthritis of the knee (Jevsevar). The American College of Rheumatology conditionally recommends a trial of these agents in patients who have failed initial therapies (Hochberg, et al). In this case, primary osteoarthritis is the etiology of the patients knee symptoms and two prior Synvisc injections were ineffective. All told, the guidelines do not support the requested Euflexxa injection as medically necessary for treatment of this patients medical condition.