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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for physical and occupational therapy services provided at a skilled nursing facility. Findings:  The physician reviewer found that there is a lack of support in the medical literature for the services at issue in this clinical setting. The patient is being treated with diagnoses including metastatic breast cancer as described above. She received physical and occupational therapy as part of the patients SNF level care for two weeks after previously receiving custodial level care. The patient has skilled nursing needs. The patient has pain interfering with function, which needs to be assessed and treated. The patient requires oversight of her medical conditions and medication management. The patient is at risk for secondary complications of immobility such as pressure ulcers and contractures. However, there was no new injury or impairing condition. The patient is receiving care that can be provided by the patients non-skilled caregivers with periodic skilled oversight and modification of the care plan if needed. The patients care can be appropriately provided at a custodial level. Based on the documentation provided, ongoing SNF level skilled therapy services are not medically necessary. Therefore, physical and occupational therapy services provided at a skilled nursing facility were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 physical medicine and rehabilitation 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 35-year-old male enrollee has requested for Provigil for treatment of his low back pain. Findings:  The physician reviewer found that there is no documentation that the patient has narcolepsy apnea or shift work disorder. It appears that Provigil is being used to counteract sedation and lethargy from the Duragesic patch. Provigil is not medically indicated for this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

The mother of a 14-year-old female enrollee requested authorization and coverage of an electric bone growth stimulator. The Health Plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees finger status post fracture.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested equipment is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old male enrollee has requested Avastin therapy for the treatment of his metastatic head and neck cancer. Findings:  Three physician reviewers found that there is insufficient evidence to support the use of Avastin in this setting. It has been approved for use in a few types of cancer and is being actively studied in clinical trials in multiple other tumor types. Based upon the evidence available to date, Avastin remains an unproven therapy in this clinical setting and offers no clear treatment advantage for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old male enrollee requested authorization and coverage for the medication Viagra. The health plan has denied this request indicating that Viagra is not medically necessary for treatment of the enrollees erectile dysfunction.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the health plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 12 weeks of Sovaldi for treatment of the enrollees chronic hepatitis C virus genotype 2b. Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. Per the guidelines, in treatment-naive genotype 2 patients, therapy is recommended with Sovaldi/Daklinza or Epclusa. This is based on the two studies for Sovaldi/Daklinza, and the ASTRAL-2 trial for Epclusa. Sovaldi and ribavirin are no longer recommended. The guidelines cite data showing that delay in treatment may result in decreased survival. For these reasons, although hepatitis C treatment is needed, the request for Sovaldi and ribavirin 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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for the medication, Trulance (plecanatide) for chronic idiopathic constipation. She was started on a different medication but she reported she did not have a great response. Her gastroenterologist has now prescribed Trulance. According to the medical literature, the FDA has approved Trulance for chronic idiopathic constipation.  Its safety and efficacy were established in a trial study.  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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old male enrollee has requested the Pegasys ProClick Autoinjector for treatment of his hepatitis C. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication for the treatment of this patient.  The American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) have provided guidance on the recommended treatments for patients with chronic hepatitis C infection who are treatment-experienced, as in this patients case.  Per AASLD/IDSA, hepatitis C genotype 1 patients who are treatment-experienced and eligible to receive interferon are best managed with sofosbuvir plus weight-based ribavirin and weekly peginterferon.  Per the current medical evidence, there is sufficient support for the recommended treatment regimen in this clinical setting.  All told, the requested Pegasys ProClick Autoinjector is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.   Findings:  Two physician reviewers found  the American College of Radiology (ACR) recommended that the technique be removed from the investigational category due to the advantages this tomographic method brings to radiologists interpreting mammograms. This procedure often allows the reader to separate dense glandular elements from underlying architectural distortion/mass resulting in a decrease in callbacks and increase in detection of small cancers. For these reasons, the addition of tomosynthesis to the usual two dimensional imaging mammographic protocol was likely of more benefit to this patient than if the exam had been done with two dimensional technique alone. Therefore, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Final Result: Two 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 diagnostic radiology 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested an inpatient hospital stay for treatment of his medical condition.  Findings:  The physician reviewer found that this patient was treated for acute pancreatitis, hypertension and diabetes.  He was not tolerating an oral diet.  He continued to require intravenous fluids and had an increasing white blood cell count which is concerning for untreated infection.  Subsequently, he was voiding and tolerating an oral diet.  His vital signs were stable and afebrile, and his laboratory test results were normalizing.  The patient was using oral analgesic medications for chronic pain issues.  At this point, he could have been safely transferred to a lower level of care.  All told, inpatient hospital stay was medically necessary initially, but not thereafter. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  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

A 28-year-old female enrollee has requested for a continuous glucose monitoring system (CGMS), sensors and related supplies for treatment of her diabetes.    Findings:  The physician reviewer found that the 2007 guidelines from the American Association of Clinical Endocrinologists recommend that providers arrange for continuous glucose monitoring for patients with type 1 diabetes mellitus with unstable glucose control; continuous glucose monitoring is particularly valuable in detecting both unrecognized nocturnal hypoglycemia and postprandial hyperglycemia.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old female enrollee requested  Sovaldi for medical treatment of the her hepatitis C.  Findings:  Two physician reviewers found that hepatitis C is a chronic disease that can progress to cirrhosis, liver failure, hepatocellular carcinoma and is associated with a multitude of extrahepatic complications.  Screening for hepatitis C is indicated in the setting of chronic liver disease and in patients at risk, and treatment of hepatitis C is indicated when no contraindications exist.  The current medical evidence does not support waiting for advanced fibrosis prior to treatment.  This patient is eligible for interferon-based therapy as prescribed, and the current medical evidence supports the requested treatment in this clinical setting.  Thus, Sovaldi is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 57-year-old male has requested a continuous glucose monitor for treatment of diabetes.  Findings:  Two physician reviewers found that there are several articles that support the value of real-time continuous glucose monitor in improving diabetes control.  This patients autonomic neuropathy interferes with his diabetic management.  The patient is correct in stating that the symptoms of autonomic neuropathy mimic those of a hypoglycemic reaction.  This condition and his nighttime hypoglycemia place him at risk for hypoglycemic seizures, coma, and death during sleep.  His current monitoring leaves unattended gaps in his blood glucose excursions even though he monitors at increased frequency.  Due to his heightened risk for severe and life threatening complications, I have determined the requested continuous glucose monitor is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Otezla 30 mg, 60 tablets for 30 days. This patient has a history of chronic plaque psoriasis, and the records document that he has tried and failed therapy with topical steroids and calcipotriene. The Health Plan requires that the patient first try the preferred formulary agents, including acitretin, cyclosporine, or methotrexate, and two preferred biologic agents, which include Enbrel, Humira, Remicade and Stelara, prior to covering Otezla. The medical records fail to indicate a treatment trial or any contraindications to the use of any of the preferred agents. The formulary agents are medically appropriate and are likely to be as effective as the requested medication. Therefore, Otezla 30 mg, 60 tablets for 30 days 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the skin grafts. The use of Neox skin grafting is not supported, as there is a lack of support in the prevailing peer-reviewed medical literature regarding efficacy and safety. There is no indication in the documentation provided that the patient is a diabetic or has venous insufficiency. The use of Neox has not been demonstrated to be safe and effective for non-healing neuroma. Accordingly, the use of Neox skin grafts were not likely to be more beneficial for the treatment of the patients condition than any available standard therapy.One reviewer found that the use of Neox skin grafts were likely to be more beneficial for the treatment of the patients condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were not likely to be more beneficial for evaluation 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 sub-specialty certification in infectious diseases and is actively practicing. One Reviewer is board certified in family practice with sub-specialty certification in undersea and hyperbaric medicine and is actively practicing.  One Reviewer is board certified in podiatry 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 authorization and coverage for bariatric surgery.According to Mechanick and colleagues, Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Arterburn and colleagues indicate that National Institutes of Health guidelines recommend consideration of bariatric surgery in patients with BMI of 40 or higher or 35 or higher with serious obesity-related comorbidities. Additionally, the authors state that, Bariatric procedures should also be considered for patients with type 2 diabetes and a BMI of 30 to 35 if hyperglycemia is inadequately controlled despite optimal medical treatment. In this case, the patient does not present with clinically severe or morbid obesity. The records reflect that the patient documents a BMI that is less than 40 but greater than 35 kg/m2, without associated life threatening obesity conditions such as sleep apnea, diabetes, hypertension or cardiac disease. The patient does not meet the minimum BMI at this time to be eligible for metabolic bariatric surgery. Therefore, the requested bariatric surgery is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 general surgery with expertise in bariatric 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50 mg  100 mg for 12 weeks. Findings:  The physician reviewer found that, 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 showing a 99% cure rate when NS5A resistance is absent. However, Zepatier is significantly less effective when NS5A resistance is present, and a different regimen is needed. This patients records do not include NS5A resistance testing results. Thus, although hepatitis C treatment is needed, 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested epidermal growth factor receptor (EGFR) gene analysis and Foundation One testing for evaluation of his medical condition.  Findings:  Two physician reviewers found that the EGFR gene analysis and Foundation One testing were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Glioblastoma multiforme (GBM) is an incurable disease. The standard of care is resection of the GBM maximally followed by treatment with temozolomide. On temozolomide treatment concomitant with radiation therapy, a randomized clinical trial showed only 26.5% two-year survival compared to 10.4% in the cohort receiving radiation only. Most GBM tumors recur and then the treatment options are limited. Initially, this patient was tested for EGFR amplifications and mutations and phosphatase and tensin homolog (PTEN) loss. There is sufficient medical evidence to suggest that these two molecular markers are important predictors of response to EGFR inhibition. Subsequently, the patients tumor was submitted to Foundation One for molecular testing to identify mutations that allow enrollment in appropriate clinical trials. Recently, it has become important to identify mutations that may be amenable to targeted therapy. Researchers performed a study of 86 patients where the progression-free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. Given the above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two 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:   One reviewer is board certified in medical oncology and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee has requested a computed tomography scan of the heart for evaluation of her hypercholesterolemia. Findings:  Two physician reviewers found that upon reviewing the available medical literature, there is a paucity of support for coronary calcium scoring in an asymptomatic patient with a previous calcium score of 17. The scientific data does not support the value of the diagnostic procedure at issue to be as good as or superior to conventional modalities in treatment planning in this patient subset. Thus, the providers request for repeat evaluation of coronary calcium scoring in this patient was not likely to be more beneficial for evaluation of this patients condition than any standard alternative.