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

A 50-year-old female enrollee requested inpatient substance abuse residential treatment for medical treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the patient was stable on gabapentin and fluoxetine, with no change in dosing since admission.  She had chronic issues, but was not psychiatrically distressed.  Her behavior was noted to be impulsive and disruptive, which suggested that the setting may have been suboptimal.  The patient had 10 weeks of sobriety and had achieved the goals listed in the treatment plans.  Finally, the documentation did not include daily progress notes or serial psychiatric assessments, which are needed to evaluate the patients clinical progress, likelihood of failure or success at a less restrictive setting or the appropriateness of the disputed service.  All told, inpatient substance abuse residential treatment services not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of the enrollees hepatitis C virus.  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. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks, as in this patients case. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni for eight weeks 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 physician 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 51-year-old female enrollee requested authorization and coverage of continued residential chemical dependency treatment. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees alcoholism.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary.
Appeal type: Urgent Care
Decision: Upheld

A 22-year-old female enrollee has requested services be performed out of state on an urgent basis for the treatment of her medical condition. Findings:  The physician reviewer found that the patients condition had been ongoing since she had traveled out of the country and she was evaluated for gastrointestinal complaints upon her return home. The consultation notes provided do not document reports of blood in the stool. As of the date of service at issue, the patient was experiencing continued symptoms of an ongoing condition that had begun some time earlier. The patients symptoms were not of a level of severity that precluded travel back home. Thus, further workup of the patients symptoms could have been delayed until she flew back to the plans service area. In sum, the patients symptoms did not meet prudent layperson criteria for urgent care. A prudent person with the patients prior history would not have considered her ongoing symptoms to be an urgent medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for dental procedure codes D7953 and D9223. Findings:  The physician reviewer found that the clinical records fail to demonstrate the dental necessity of the requested services.  The submitted documentation indicates that the procedure of grafting, D7953, was recommended to facilitate placement of a dental implant in the extraction site of tooth number 26.  The dental literature supports that following the extraction of a tooth, while a bone graft will likely result in slightly greater preservation of the bone in the tooth socket, the socket will spontaneously heal with regeneration of the bone in the socket.  As there is a lack of evidence of a clinical defect requiring grafting and the bone socket would be expected to heal spontaneously, the dental necessity of D7953 has not been established.  Additionally, the appeal documentation does not show any indication for the requested procedure D9223, deep sedation/general anesthesia.  The literature shows risk with the service requested, and alternatives to sedation and general anesthesia are available.  In sum, dental procedure codes D7953 and D9223 are not dentally necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not dentally necessary for treatment of the patients dental condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in dentistry 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 25-year-old female enrollee requested Anser IFX testing for medical evaluation of her medical condition.  Findings:  Three physician reviewers found that the superior effectiveness of the services at issue has not been established.  Based on the medical records submitted for review, it is not clear if the Remicade dosage has been increased.  Additionally, details regarding response to treatment were not provided.  This test is not the standard of care, and there is a lack of clinical guidelines supporting Anser IFX testing in this clinical setting.  Therefore, Anser IFX testing was not likely to have been of greater benefit than other methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Spinraza. The records provided for review document that this patients diagnosis is a severe phenotype of spinal muscular atrophy (SMA) that has substantially deteriorated his ability to function. The documentation reports that the patient has trace arm movement and he is no longer able to maneuver his wheelchair. The patients provider recommended treatment with Spinraza, which is a U.S. Food and Drug Administration (FDA) approved medication for the treatment of patients with SMA. Recent studies have demonstrated that Spinraza is safe and effective for use in this patient population. Researchers found that Spinraza addresses the insufficient level of SMN proteins in this patient population by promoting increased production of full-length SMN proteins. Given the support in the medical literature, the requested Spinraza is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurology with expertise in neurodegenerative disorders 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 Sovaldi and ribavirin for 12 weeks for treatment of his hepatitis C virus (HCV).  Findings:  The physician reviewer found that the proposed treatment is medically necessary and is considered the standard of care for the treatment of the patients with HCV genotype 2 and is expected to prevent further damage of the liver. According to the joint guidelines from the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) daily sofosbuvir (Sovaldi) and weight-based ribavirin for 12 weeks is recommended for treatment-naive patients with hepatitis C genotype 2. As such, the requested treatment is medically necessary and is considered the standard of care for the treatment of the patients with hepatitis C genotype 2. Final Result: The reviewer determined that the requested medications 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the brand name medication Flomax. The submitted documentation fails to demonstrate the medical necessity of the requested medication. When a generic drug product is approved by the U.S. Food and Drug Administration (FDA), it has met rigorous standards established by the FDA with respect to identity, strength, quality, purity and potency. Generic drugs are required to have the same active ingredient, strength, dosage form and route of administration as the brand name product. Through review of bioequivalence data, the FDA ensures that the generic product performs the same as its respective brand name product. This standard applies to all generic drugs, whether immediate or controlled release. In this case, the records do not document that the patient has had a significant adverse reaction to the generic drug tamsulosin. The efficacy of both the brand name and generic drug are equivalent. Therefore, the brand name medication Flomax is 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Remicade induction and maintenance infusions. In a systemic review on medical therapies for inflammatory bowel disease, Talley and colleagues found that tumor necrosis factor (TNF) inhibitors, such as infliximab (brand name Remicade), are strongly recommended based on their efficacy at inducing remission in patients with moderate to severely active symptoms. The American Gastroenterological Associations guidelines for initial treatment of Crohns disease recommend using anti-TNF- drugs, such as infliximab, to induce remission in patients with moderately severe Crohns disease that is refractory to other therapies. The guidelines further recommended anti-TNF monotherapy over no therapy or thiopurine monotherapy, and the continued use of anti-TNF  drugs to maintain remission. Alternatives to anti-TNF therapy, such as immunosuppressants, aminosalicylates, corticosteroids, and antibiotics, were not recommended. In this case, the patient has moderate Crohns disease. He is dependent on corticosteroids. The records noted negative laboratory test results for tuberculosis and hepatitis B. Without treatment, the patient is at risk for complications from Crohns disease, such as fistula, stricture, hospitalization, and need for surgery. Given the current medical literature, the requested medication regimen is medically indicated in this setting. Therefore, Remicade induction and maintenance infusions are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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: The patient has requested authorization and coverage for an Aimovig 70 mg/mL autoinjector. The American Headache Society (AHS) notes that treatment with monoclonal antibodies to calcitonin gene-related peptide (CGRP) may be indicated for patients with chronic migraines with an inadequate response to topiramate. The AHS recommends that clinicians and patients reassess the benefits of CGRP monoclonal antibody therapy after three to six months and continue treatment if benefits can be documented, such as a reduction in mean monthly headache days of 50% or more relative to the pretreatment baseline. The U.S. Food and Drug Administration (FDA) has approved the use of Aimovig, a CGRP antagonist, for the preventive treatment of migraines in adults. In this case, the patient has a history of chronic migraines with inadequate response to topiramate and nortriptyline. Given that the patient fits AHS criteria for treatment with CGRP monoclonal antibody therapy, the requested medication is medically indicated. Therefore, Aimovig 70 mg/mL autoinjector 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female enrollee requested authorization and coverage of gastric bypass. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary depending on the results of a psychological evaluation.
Appeal type: Medical Necessity
Decision: Overturned

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 recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 6 patients should be treated with Epclusa for 12 weeks, based on a 100% cure rate in the ASTRAL-1 trial. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment of hepatitis C is needed, and the requested treatment with Epclusa 400-100 mg tablets for 12 weeks 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: Upheld

Nature of Statutory Criteria/Case Summary: parent of an enrollee has requested authorization and coverage for Nutropin AQ Nuspin 20 mg. Findings:  The physician reviewer found that there is a lack of data to comment on whether there is any component of genetic short stature.  The patients bone age is not delayed.  In growth hormone deficiency, a bone age is characteristically delayed.  Of note, the bone age study was obtained approximately one year before growth hormone therapy was recommended.  Although the growth hormone stimulation test is low, there are no insulin-like growth factor 1 (IGF-1) data to confirm this.  Growth hormone stimulation tests are known to have a high rate of false positivity and low sensitivity.  Accordingly, this may represent a false positive.  There is a lack of data on height velocity, which is also an important component of the rationale for supporting a diagnosis of growth hormone deficiency.  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 pediatrics with sub-specialty certification in pediatric endocrinology 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 authorization and coverage for Mekinist tablets once a day. Findings:  The physician reviewer found that AVM is a rare, congenital vascular growth that progresses throughout life, causing complications that include bleeding, functional deficits, deformity, and high-output cardiac failure. Traditional management with embolization or surgical resection, with or without embolization, carries a high recurrence rate. Currently, there are no approved treatments by the U.S. Food and Drug Administration (FDA) for AVMs. Couto and colleagues have found that mitogen-activated protein kinase 1 (MAP2K1) somatic mutations have been implicated in the development of extracranial AVMs. Therefore, the mitogen-activated protein/extracellular signal-regulated kinase (MEK) inhibitor, Mekinist (trametinib), has been used to treat extracranial AVMs in case reports, according to Lekwuttikarn and colleagues. There are case reports of effectively treating extracranial AVMs in patients who have failed sirolimus. In this case, the patient has an identified PTEN mutation that explains his extensive oncologic history. The patient has previously been treated with maximal dose of sirolimus, without clinical response. The patients pediatric oncologist is requesting coverage for treatment with Mekinist in order to prevent recruitment of new blood vessels to diminish the risk of AVM recurrence. Based on the progressive nature of AVMs, the lack of available FDA-approved medical treatments for AVMs, the high recurrence rates with embolization, and the failure of maximal dose sirolimus in this patient, the use of Mekinist (trametinib) is the best available option for this patient. Therefore, Mekinist tablets once a day is medically necessary for the treatment of the patients medical condition.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 vascular 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: Medical Necessity
Decision: Upheld

A 56-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 depression.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.