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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found according to the 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, regardless of fibrosis stage. The guidelines recommend that treatment-naive genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results. However, NS5A resistance testing is not provided, so the appropriate treatment duration cannot be determined. For these reasons, treatment with Zepatier for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 65-year-old male has requested bilateral total knee arthroplasty for treatment of his knee pain.  Findings:  The physician reviewer found that the relationship of obesity to outcomes following total knee arthroplasty has been the subject of controversy.  Some studies have reported that any degree of obesity has a negative effect on outcomes.  Other studies have indicated that moderate obesity does not affect outcomes, and that with increased mobility, subsequent weight loss may be enhanced.  Researchers have compared outcomes in obese and normal patients, and there are studies which have found no significant difference in survival or perioperative complications.  Since surgery in the obese carries some risk of additional complications, weight loss prior to surgery may be advisable.  However, since substantial improvement and high patient satisfaction rates have been reported, total knee replacement is an appropriate treatment option in this clinical setting.  In this patients case, the presence of significant joint damage has been documented.  Additionally, he has not benefited from conservative management.  Despite the presence of obesity, the requested procedure is likely to offer significant benefits to this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested urine estrogen metabolite testing for treatment of her medical condition. Findings:  The physician reviewer found that review of the submitted evidence indicates the patient is on hormone therapy and also has a number of medical problems that may put her at additional risk using hormone therapy, in particular compounded hormones. The patient requests urinary testing as a tool to make such use safer by testing her urinary hormone levels.. Despite claims to the contrary, evidence is inadequate to support increased efficacy or safety for individualized hormone therapy regimens based on salivary, serum, or urinary testing. Due to the pharmacokinetics of estrogen metabolism, urinary estrogen levels do not correlate with serum levels of the hormones being measured. Such measurements do not allow for a more safe use of these compounded products. Moreover, there is a lack of literature demonstrating the utility for urinary testing to guide the use of hormone therapy. Also, the American College of Obstetricians and Gynecologists (ACOG) specifically recommends against such testing. For the reasons provided, urine estrogen metabolite testing is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are 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 obstetrics and gynecology 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 inpatient mental health services for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  This patient suffers from a serious mental illness that impacts mood and cognition, and is associated with functional impairment across multiple domains, poor clinical outcomes and heightened risk of suicide.  The active treatment provided at the inpatient setting was reasonably expected to improve her condition and prevent a more serious episode of illness.  Further, the duration of treatment was consistent with community standards for a case of such severity while the hospital-based care represented a safe and appropriate placement consistent with good medical practice.  Finally, the disputed course of treatment enabled a seamless transition to an appropriate, less restrictive treatment setting.  Thus, the inpatient mental health services were medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for private duty nursing for treatment of the enrollees seizure disorder. Findings:  The physician reviewer found that in the medical literature, colleagues found that approximately one in five patients born before 26 weeks gestation will develop major neurodevelopmental disorders. The overarching goal of home health care is to optimize each patients health and function while minimizing recurrent or prolonged hospitalizations through the provision of comprehensive, family-centered health care rendered in a nurturing home environment. According to this patients home nursing health plan, home nursing is indicated to monitor vital signs, perform nursing assessment, provide gastrostomy tube care, implement seizure precautions, monitor lungs sounds, perform oral suctioning, assists with range of motion and monitor for skin breakdown. While the family may be able to meet the ongoing needs of the patient in the short-term, this is not a sustainable long-term treatment plan. Common indications for private duty nursing include the administration of medications, monitoring oxygen saturations, and enteral feeding, which are required in this case. Given the ongoing seizure concerns, oxygen needs, gastrostomy tube cares, oral suctioning and global developmental delays, the request for private duty nursing is medically necessary for treatment of this patients medical condition. 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 pediatrics with sub-specialty certification in neurodevelopmental behavioral pediatrics 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

The parent of a 12-year-old male enrollee has requested Genotropin for the treatment of his severe growth failure secondary to multiple psychiatric medications. Findings:  The physician reviewer found that the consensus of literature reports document that growth impairments may accompany the use of chronic stimulant medications, there does not appear to be a consensus on the long-term impairment on adult height. It does not appear that the mechanism for the alleged adverse effect of these drugs on height and weight has been established. Similarly, I am unaware of any study that has examined the effect of GH therapy given in attempt to counter the side effects of these drugs. For these reasons, I find that the medical necessity of GH therapy in this instance has not been established.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female enrollee requested authorization and coverage of out-of-network chiropractic care for the treatment of  fibromyalgia.  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 services are  medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for biofeedback therapy. The long-term efficacy of biofeedback in addition to standard pelvic floor pelvic therapy for management of patients with urinary incontinence remains unknown. A recent randomized trial concluded that, this preliminary study suggests that pelvic floor muscle training, with and without biofeedback, is associated with increased muscle strength, myoelectric activity, precontraction of pelvic floor muscles, and improved quality of life in postmenopausal women with stress urinary incontinence. Researchers found that pelvic floor muscle training is effective for treatment of stress urinary incontinence. However, the authors cautioned that there was no apparent add-on effect of biofeedback training in short-term follow-up. Thus, the medical literature supports the clinical utility of pelvic floor physical therapy and suggests that the addition of biofeedback does not substantially contribute to improved health outcomes. For these reasons, the requested biofeedback therapy was not and is 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 requested biofeedback therapy was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that requested biofeedback therapy was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollees parent has requested authorization for Nutropin AQ Nuspin for the treatment of Short Stature. Findings:The physician reviewer found that a review of the records indicates the patient was initially seen for concern about familial short stature.  Bone age was delayed vs. chronological age.  The final adult height estimate was over the mid parental target height. The baseline labs were all normal including thyroid tests. No therapeutic interventions were initiated at that time. On a return visit, the patient demonstrated sub-optimal interval height velocity with height deceleration. Growth hormone therapy was started at that time. Sub-optimal interval height velocity on the current dosage of growth hormone persisted despite a dosage increase. The patient has a diagnosis of Idiopathic Short Stature, which is a Food and Drug Administration (FDA) approved diagnosis for growth hormone. However, the approval criteria include a predicted adult height below the 1st percentile. To meet the predicted adult height criteria, the patients predicted height must be below 160cm (63 inches), as the patient is a male. The growth curve documents poor growth and bone age delayed.  However, the patients predicted height does not meet the criteria for approval of growth hormone treatment. The requested treatment with Nutropin AQ Nuspin is not appropriate.Final Result: The reviewer determined that the service at issue is not medically necessary for treatment of the patients condition. Therefore, the health plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in Pediatric Endocrinology and is actively practicing.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of her hepatitis C virus (HCV).  Findings:  Two physician reviewers found that per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Thus, the recommendation is not to deny patients treatment if they have early stage disease, but to provide treatment to avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from HCV. Moreover, recommendations for treatment-experienced chronic HCV patients with genotype 1b support Harvoni stating Recommended for treatment-experienced patients with HCV genotype 1b infection: Daily fixed-dose combination of ledipasvir/sofosbuvir for 12 weeks is recommended for treatment-experienced patients with HCV genotype 1b infection. All told, the request for Harvoni for 12 weeks is medically necessary for treatment of the patients medical condition. Final Result: Two 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: One reviewer is board certified in gastroenterology and is actively practicing. Two 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 22-year-old male enrollee has requested an epidural injection for treatment of the enrollees cervical stenosis and radiculopathy.  Findings:  The physician reviewer found that the epidural steroid injection was medically necessary for this patients pain and was indicated given the findings on cervical MRI and physical exam. In particular, the patients MRI was significant for cervical spinal stenosis at C5-6 and C6-7 with a 4 mm, diffuse broad based disc bulge and compression of the cervical cord. Additionally, the provider noted a positive Spurlings test on the left side, which is a medical maneuver that assesses nerve root pain most likely due to radiculopathy. The patient has tried and failed to receive relief with medications and physical therapy. For these reasons, the epidural steroid injection is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested authorization and coverage for modafinil (Provigil) for treatment of the enrollees narcolepsy. Findings:  Two physician reviewers found that this patient does not have a diagnosis of narcolepsy that is supported by the provided records. Her symptoms are suggestive of this condition, however, references to her previous sleep study document that it did not show the hallmarks of the condition. Although the HLA-DQB1 0602 allele is more common in patients with narcolepsy, approximately 25% of the population are positive for this allele, and the test result is irrelevant in the setting of a non-suggestive sleep study. Final Result: Two reviewers determined that the requested medication 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: Two physician reviewers are board certified in sleep medicine and neurology and are actively practicing. One physician reviewer is board certified in internal medicine, pulmonary medicine and critical care medicine 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for prostatic arterial embolization (CPT 37243) surgery. The American Urological Association (AUA) guidelines state that, prostatic arterial embolization is not recommended for the treatment of lower urinary tract symptoms (LUTS) attributed to benign prostatic hyperplasia (BPH) outside the context of a clinical trial. First-line therapies for management of BPH includes alpha-blockers, 5 alpha reductase inhibitors, phosphodiesterase inhibitors, and anticholinergic medications. The standard of care for management of patients with BPH not responding to medical therapy is transurethral resection of prostate (TURP). Holmium laser enucleation of the prostate (HoLEP) and simple prostatectomy are options for patients with large glands measuring 100 cc or greater, as this patient. Current data on prostatic arterial embolization is limited to case series and retrospective comparisons. There is a lack of randomized trials demonstrated improved symptomatic relief or survival rates with prostatic arterial embolization over TURP, HoLEP, or simple prostatectomy. Accordingly, the requested prostatic arterial embolization (CPT 37243) surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested prostatic arterial embolization (CPT 37243) surgery is 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 requested services are 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 urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 50-year-old female who has had pain in the upper outer quadrant of her right breast for several years. Mammograms of the right breast performed in October 2002, March 2003, October 2003 and November 2005 were negative and ultrasounds performed in October 2002, March 2003, October 2003 and January 2004 had benign findings. An ultrasound-guided biopsy of the right upper outer quadrant of the breast was performed in February 2004 with the pathology results showing fibrocystic changes without atypia. An ultrasound in August 2004 showed benign-appearing findings with no explanation for the patients pain. A surgical consultation dated September 2004 noted that the patients mother had lung cancer and her sister-in-law died from breast cancer. An MRI was suggested to the patient with her next mammogram.The MRI of the right breast was performed in October 2004 and showed focal enhancement at 9 oclock, which was felt to be benign microcysts or fibroadenoma. A targeted ultrasound was performed in October 2004, which showed a cluster of microcysts at 12 oclock and a cyst at 10 oclock. The MRI findings were believed to correlate with the cyst at 10 oclock.   The ultrasound findings were considered benign and a follow-up mammogram in 1 year was suggested.  The patient is requesting reimbursement for the MRI, but the Health Plan has denied coverage based upon their determination that the diagnostic procedure was not medically necessary.The indications for breast MRI include: determination of the extent of malignant disease prior to surgery, evaluation of residual tumor after lumpectomy with positive margins, to distinguish postoperative scar from tumor recurrence, detection of occult primary cancer presenting with axillary metastases, follow-up of tumor response after chemotherapy, to screen high risk patients, and to provide additional information when other tests are equivocal. Pain, which is a common breast complaint, is rarely a symptom of malignancy, and persistent pain is not an established indication for breast MRI. The patient was properly evaluated with mammography and ultrasound and after the benign biopsy, the likelihood of additional meaningful information from an MRI was low.Based upon the information set forth above, I have determined the diagnostic procedure at issue was not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.