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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for physical therapy with a board certified orthopedic clinical specialist (OCS). According to the medical record, the enrollee has a history of right shoulder dislocations. A magnetic resonance imaging showed a large tear of the superior labrum and the enrollee underwent right shoulder superior labrum anterior posterior (SLAP) lesion repair, arthroscopic subacromial decompression, distal clavicle undersurface resection, and lysis of adhesions with manipulation under anesthesia. Physical therapy was prescribed post-operatively.  The treating physician assistant indicated it is imperative the enrollee start physical therapy as soon as possible to gain back strength and motion.  It is standard of care for enrollees to undergo physical therapy after any intra-articular shoulder surgery, including a shoulder stabilization and superior labrum anterior posterior (SLAP) lesion repair. It is typically written for a series of progressive exercises, starting with passive range of motion for the first four to six weeks, followed by active range of motion for six weeks, and subsequently strengthening for the shoulder until return to sports/work is allowed.  The outcomes of the procedure performed suggest there is not a need for specialized physical therapy for this procedure.  In a review of SLAP repairs and biceps tenodesis, the medical literature found good outcomes with SLAP repair. The majority of surgeons do not require a certified physical therapist and the use of a specialized orthopedic physical therapist is relatively uncommon. Therefore, a board certified orthopedic clinical specialist is not necessary.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in orthopedics 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 43-year-old female enrollee requested authorization and coverage of the medication Provigil. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees daytime drowsiness. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Overturned

A 27-year-old female enrollee requested laparoscopic gastric sleeve surgery for medical treatment of her morbid obesity.  Findings:  The physician reviewer found that the requested laparoscopic gastric sleeve surgery is medically necessary for treatment of the patients medical condition.  She has been appropriately screened and cleared for bariatric surgery by numerous providers including a bariatric surgeon and a psychiatrist.  She meets generally accepted criteria for bariatric surgery (Buchwald, et al). As such, the requested procedure is medically necessary for treatment of the patients clinically severe obesity.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting reimbursement for partial hospitalization program (PHP) services and intensive outpatient program (IOP) services. He was admitted to the partial hospitalization program to address symptoms of depression and anxiety. The enrollee was compliant with regards to session attendance and sharing what was on his mind. The discharge report indicated there was a good possibility the enrollees functioning would continue to deteriorate. The enrollee was transferred to the intensive outpatient program. The Level of Care Utilization System (LOCUS), a level of care assessment tool to support accurate level of care recommendations was used in this review. The enrollees composite LOCUS score correlates with low intensity community-based services without frequent contact. Medical evidence supports the services at issue in this clinical setting.Final Result: The reviewer determined that the requested service were medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old female enrollee has requested authorization and coverage for insertion of a portacath for treatment of her hypokalemia. Findings:  The physician reviewer found that clinical features of hypokalemia vary greatly, and their severity depends in part on the degree of hypokalemia. Fatigue, myalgias and muscle weakness or cramps of the lower extremities are common. Severe hypokalemia may result in complete paralysis, hypoventilation, or rhabdomyolysis.  Given the risk of infection and other complications, the use of portacath is standard of care.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for the requested treatment plan, as recommended by the provider and as listed in the patients complaint. The patient presents with a disabling left knee issue pertaining to painful dislocations of the patellofemoral joint and full thickness chondral loss of the patella, as well as the trochlear groove of the femur. She has tried and failed conservative treatment. Her provider has recommended surgical intervention. Based on current medical literature, the recommended matrix-induced autologous chondrocyte implantation (MACI) procedure is appropriate to regenerate articular cartilage and stabilize the patellofemoral joint. Recent data show that MACI has evolved since its inception and long-term follow-up support its use in this patient population. Given this support, the requested treatment plan, as recommended by the provider and as listed in the patients complaint, 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 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 orthopedic surgery 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: Overturned

A transgender female enrollee requested bilateral breast augmentation surgery for medical  treatment of her gender dysphoria.  Findings:  The physician reviewer found that the submitted medical documentation adequately establishes the medical necessity of bilateral breast augmentation surgery. The patient has undergone hormonal therapy without significant improvement. Documentation from the patients providers indicates she experiences significant morbidity resulting from the lack of breast development. The patient presents with well-documented gender dysphoria and her recent examination and photographs are consistent with a male pattern of breast development. Thus, her breast development is considered abnormal for a female. The abnormal condition results from the patients diagnosis of gender dysphoria. In sum, the proposed bilateral breast augmentation surgery is medically necessary and considered reconstructive surgery rather than breast enhancement or cosmetic surgery.
Appeal type: Medical Necessity
Decision: Overturned

A 37-year-old female enrollee has requested a bunionectomy on her right foot for the treatment of her foot pain.    Findings:  The physician reviewer found that hallux valgus deformity is a painful deviation of the great toe laterally, causing a pronounced bump to the medial aspect of the forefoot. Deviation of the first toe joint may also cause arthritis. As seen with this patient, the large medial bump can cause severe pain to the joint area, as well as severe friction with subsequent skin breakdown. Most patients instinctively try wider shoes to alleviate the pain. Currently, the standard of care is to surgically correct bunions to avoid medial eminence ulcerations. This is especially so for diabetics, such as this patient. Surgical correction of the bunion will afford better shoe fit, reduced chance of skin ulcerations, and comfortable ambulation.
Appeal type: Experimental/Investigational
Decision: Overturned

A 59-year-old female enrollee has requested magnetic resonance imaging (MRI) of the breast for treatment of her bilateral breast densities.  Findings:  Two physician reviewers found that the medical literature shows that a patient who has inherited a harmful mutation in BRCA1 or BRCA2 is about five times more likely to develop breast cancer than a patient without such mutation. Based on the information provided, this patients estimated risk for developing invasive breast cancer over her lifetime (to age 90) is 34.9% compared to 9.3% for a woman of the same age and ethnicity from the general population. In attempts at early diagnosis, studies support the high sensitivity of MRI, ranging from 71% to 100% versus 16% to 40% for mammography in high-risk populations. Further, the American College of Radiology (ACR) appropriateness criteria recommends MRI for evaluation of high risk patients given its increased sensitivity. Clearly, the increased sensitivity of MRI has been established in the screening of high risk patients. Given the recommendations from the ACR and the National Cancer Institute (NCI), this patient meets the criteria established for screening MRI of the breast.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested a 12 week prescription for Sovaldi and Daklinza for the treatment of his hepatitis C infection.   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. Patients with cirrhosis are high priority for therapy. Per the guidelines, cirrhotic treatment-naive genotype 2 patients should be treated with Sovaldi and ribavirin or Sovaldi and Daklinza for 16-24 weeks. These recommendations are based on multiple randomized clinical trials (Zeuzem, et al; Lawitz, et al; Sulkowski, et al). Thus, based on current guidelines, the patient requires at least 16 weeks of treatment with Sovaldi and Daklinza to treat his hepatitis C virus. Since the requested treatment duration of 12 weeks is inconsistent with current guidelines, the requested regimen is not medically necessary for treatment of the patients condition. Final Result: The reviewer determined that requested regimen of Sovaldi and Daklinza for 12 weeks 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 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: The patient is an enrollee who was diagnosed with alopecia areata (AA). The records noted that this condition affected greater than 50% of her scalp, and the patient had failed treatment with topical corticosteroids, intralesional Kenalog, and systemic corticosteroids. The documentation noted that patient had been treated with Xeljanz for two months, with near complete hair regrowth. A single patch of hair loss was noted to remain on her mid frontal scalp, and her eyebrows were laterally thinned. The patient has requested authorization and coverage for Xeljanz. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. At issue in this case is whether Xeljanz is medically necessary for treatment of the patients medical condition. AA is a chronic immunological disorder characterized by round or oval patches of non-scarring hair loss. Alopecia universalis is a form of AA which includes eyebrows, eyelashes and facial hair. Depending on the extent of involvement, AA can have a significant negative impact on quality of life. Topical immune therapies or immunosuppressive drugs are typically used with mixed success. Various therapies for the disease may have efficacy in different patients, making a universal treatment algorithm difficult to implement. Patients should be managed on an individual basis, with the final outcome based on the cosmetic regrowth of hair. Maintenance therapy is also important in patients that do achieve acceptable regrowth. Xeljanz (tofacitinib citrate) is an oral janus kinase (JAK) 1/3 inhibitor, which has been demonstrated to be effective for the treatment of AA. Medical literatures indicate systemically administered pharmacological inhibitors of JAK family protein tyrosine kinases prevented the development of AA, while topical administration promoted hair regrowth and reversed the established disease. In this case, the patient has failed treatment with topical corticosteroids, intralesional Kenalog, and systemic corticosteroids but showed near full hair regrowth after two months of treatment with Xeljanz. Medical evidence supports the requested medication in this case. Therefore, Xeljanz 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 dermatology 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 buprenorphine for treatment of his medical condition.  Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for buprenorphine has not been established. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. According to the documentation submitted for review, the patient is not participating in a comprehensive pain management program. In addition, researchers reported that opioid agonist-antagonist have been approved for opioid addiction. Doctors are often hesitant to prescribe agonist-antagonist and partial agonist to opioid tolerant patients, fearing that these drugs may precipitate withdrawal.  Researchers also reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. For the reasons provided, the patients request for buprenorphine is not medically necessary. 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Venclexta 100 mg tablets and Imbruvica 420 mg tablets. The use of Venclexta, alone or in combination with Ibrutinib, for T-cell prolymphocytic leukemia (PLL) is not within the current standard of care. A case report of two patients with T-cell PLL reported anti-tumor activity with Venclexta (Boidol, et al.). The U.S. National Institutes of Health (NIH) announced a clinical trial to evaluate the combination of Venclexta and Imbruvica in T-cell PLL. Therefore, Venclexta 100 mg tablets and Imbruvica 420 mg tablets are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested medication regimen is 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:  One reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certification in medical oncology and is 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Strattera for treatment of his attention deficit hyperactivity disorder (ADHD) and depression.  The physician reviewer found that Strattera is a selective norepinephrine reuptake inhibitor used to treat patients with ADHD. Strattera is a non-stimulant, which distinguishes itself from other common pharmacologic interventions for ADHD. Stimulant medicines, such as methylphenidate and amphetamine-based products remain the gold-standard treatment for ADHD. The stimulants exert their primary effect on the dopamine system. Although contemporary psychiatric practice aims to limit polypharmacy, there is no contraindication to concomitant Strattera and stimulant therapy. However, this patients documentation does not include a psychiatric evaluation, diagnostic assessment, medication history, clinical rating scales or serial progress notes to support an indication for the requested medication. Thus, based on the documentation provided, the requested Strattera is not supported as medically necessary for treatment of this patients ADHD. 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.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee has requested Rozerem for the treatment of her insomnia and nemaline myopathy. Findings:  The physician reviewer found that Rozerem showed few side effects and was unlikely to prove habit forming (Griffiths and Johnson). Ambien, Ambien XR, and Lunesta have a large number of well designed clinical trials that show both effectiveness and safety given appropriate clinical monitoring for untoward effects. It is reasonable for the Health Plan to recommend these agents as preferred agents, given their proven track record of safety and efficacy. Rozerem certainly has its own set of benefits, but none that are specifically required to be used in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hyaluronan (Supartz) injections. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, there is no history of viscosupplementation in the past. However, the patients treatment options are limited due to cardiovascular issues such as atrial fibrillation and essential hypertension. Furthermore, the patient has a history of elevated blood sugar, which does not support treatment with corticosteroid injections. For these reasons, the requested Hyaluronan (Supartz) injections are medically necessary for treatment of this patient. Final Result: The reviewer determined that the 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.