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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 24 weeks for treatment of his hepatitis C virus (HCV).  Findings:  The physician reviewer found that Harvoni for 24 weeks is medically necessary for treatment of the patients medical condition. The patient has chronic hepatitis C and has an advanced stage disease as he has progressed to cirrhosis. The American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) national guidelines that set the standard of care in managing and treating patients with HCV state the following Immediate treatment is assigned the highest priority for those patients with advanced fibrosis (Metavir F3), those with compensated cirrhosis (Metavir F4), liver transplant recipients, and patients with severe extrahepatic hepatitis C. Based on available resources, immediate treatment should be prioritized as necessary so that patients at high risk for liver-related complications and severe extrahepatic hepatitis C complications are given high priority. This patient has hepatitis C genotype 1, is treatment experienced having failed other medications and has evidence of cirrhosis. Hence, per the national guidelines, this patient should be treated with Harvoni for 24 weeks. Based on the support per national guidelines and peer-reviewed literature, Harvoni for 24 weeks is medically necessary in this clinical setting. 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 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

The patient is an 11-year-old male with idiopathic short stature and an apparent diagnosis of neurofibromatosis. As of February 2006, growth in height had been along the third percentile, IGF-1 and IGFBP-3 levels did not suggest GH deficiency, and GH testing with glucagon revealed normal GH responses. There was a normal MRI of the brain in 2003. In November 2005 at 10.5 years there was a normal bone age of 11 years. The projected adult height given was 52 versus a mid-parental height of 57. The current growth velocity was poor at 2.4 cm/year.At issue is whether growth hormone therapy is medically necessary for treatment of the patients medical condition.The patient meets the July 2003 Food and Drug Administration criteria for growth hormone therapy for idiopathic short stature. The submitted literature is appropriately supportive of the efficacy of growth hormone therapy for idiopathic short stature. However, although the patient meets criteria for growth hormone therapy, there is concern in treating patients with neurofibromatosis with growth hormone therapy. The clinical evidence submitted does not provide significant information regarding the patient's neurofibromatosis. Therefore, the patient's providers should confirm the patient's neurofibromatosis is not a contraindication to growth hormone therapy prior to instituting such therapy. If and when no contraindication is confirmed, growth hormone therapy should be authorized. Therefore, the Health Plan's denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old male enrollee has requested a motorized wheelchair and portable oxygen device for treatment of numerous medical conditions, including minor immobility and respiratory diseases.   Findings:  The physician reviewer found that the submitted medical records from the patients treating provider document significant functional impairment secondary to his multiple medical problems. In addition, he also has severe PAH with pressures up to 75 mm Hg. This would explain his dyspnea, edema and generalized poor exercise tolerance. The treatment of PAH includes supplemental oxygen, ideally 24 hours a day along with various vasodilators.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested Norco for treatment of her chronic pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  The current medical evidence does not support Norco in this clinical setting.  Baron and McDonald reported that chronic opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  Chronic opiates may also cause adverse outcomes.  Ballantyne and Mao reported that prolonged use of 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.  All told, Norco is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old male has requested Oxycontin 20mg tablets for treatment of his degeneration of lumbar or lumbosacral intervertebral disc.   Findings:  The physician reviewer found that based on review of the available records, Oxycontin 20mg tablets are medically necessary for treatment of this patients medical condition. The patient has a chronic pain condition due to degenerative disc disease of the spine and is status post multiple spine surgeries including spinal fusion with hardware. He has tried several modalities including physical therapy and multiple non-opioid medications. Oxycontin at the current dose prescribed by his provider while he becomes established with a pain management physician is appropriate to reduce his pain and maintain his functional status.
Appeal type: Medical Necessity
Decision: Overturned

A 35-year-old female enrollee requested authorization and coverage of surgery for treatment of Temporomandibular Joint (TMJ) Dysfunction.  The enrollees health plan denied the 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 surgery is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested prescription medication Provigil for treatment of bipolar disorder and daytime somnolence.  Findings:  The physician reviewer found that the records do not include documentation of the dosages of any of the medications she was prescribed. Although there is ample documentation of her subjective assessment of her response to Provigil, there is no particular documentation of the patients mental status examination in this regard. Without basic data on drug dosages and an objective assessment of her clinical response to Provigil, the benefit derived from this medication cannot be ascertained.
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: Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. The problem of evaluating dense breasts or suspicious calcifications is a significant issue in the field of mammography. In this clinical setting, the tomosynthesis was more beneficial than breast sonography as a screening tool.  Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in 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: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) services. Applying the child and adolescent level of care utilization system (CALOCUS), the PHP services provided were not and are not medically necessary for treatment of this patients medical condition. The patient demonstrated moderate risk of harm (score 3) with a recent suicide attempt by overdosing on Prozac and intermittent passive suicidal thoughts. The patients functional status was moderately impaired (score 3) as he was unable to attend school due to his symptoms. The patients affect became brighter. He went to lunch with a church group leader and went hiking with his family. He was forward thinking and talking of volunteering. The patients co-morbid conditions are significant (score 3) and include major depressive disorder, generalized anxiety disorder, and social anxiety disorder. However, the patient did not have serious medical problems which would require intensive monitoring. The patients recovery environment is mildly stressful (score 2), his environment is described as supportive (score 2) and his parent is willing to participate in treatment. The patient demonstrated significant response to treatment (score 2) as he was participating in treatment and his thoughts of suicide had decreased. The patient was constructive in treatment (score 2) and has been engaged with his providers. These give the patient a composite score of 17, which is consistent with intensive outpatient program (IOP). The patient continued to need treatment for his of major depressive disorder, generalized anxiety disorder, and social anxiety disorder, but this could have been done in a less restrictive environment. Therefore, the PHP services provided were not and are not medically necessary. 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 psychiatry with expertise in child and adolescent 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested balloon sinuplasty for treatment of his medical condition. Findings:  Three physician reviewers found that according to the American Academy of Otolaryngology, Head and Neck Surgery guidelines, chronic rhinosinusitis is defined as a persistent inflammatory disorder of the paranasal sinuses with symptoms of persistent facial pain, discolored nasal discharge, and symptoms that are refractory to appropriate medical management including antibiotics, nasal anti-inflammatory medications and decongestant therapy. Additionally, CT scan imaging usually documents relatively extensive mucous membrane changes within the ethmoid, maxillary and other paranasal sinuses with blockage of the ostiomeatal complex. In this specific case, CT scan imaging did not show evidence of any blockage of the ostial complex. In addition, the CT scans performed documented very minimal evidence of any active sinus infection with only mucous membrane thickening within the maxillary sinuses, but the sinus ostial pathways remained open. Clinical indications for sinus surgery have not been met in this clinical scenario. Therefore, balloon sinuplasty is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition.  Credentials/Qualifications:   All three reviewers are board certified in otolaryngology 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: Upheld

A 51-year-old female enrollee requested authorization and coverage of surgical treatment for varicose veins.  The health plan denied the enrollees request indicating that the requested surgery is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old male enrollee has requested  for a power wheelchair, group 2 standard (HCPCS K0823 x 1) and power wheelchair accessory, U-1 sealed lead acid battery (HCPCS E2365 x 2) for treatment of the enrollee, who has ankylosing spondylitis. Findings:  The physician reviewer found that power operated vehicles are considered medically necessary when the individual requires the device in order to safely perform mobility-related activities of daily living in the home setting and when no alternative assistive device such as a cane, walker, or manual wheelchair will effectively achieve these goals. In addition, the individual must have demonstrated a willingness and ability to safely operate the device. Finally, the individual's residence must be able to accommodate the device.  In the case under review, all of the criteria necessary to demonstrate medical necessity have been met.
Appeal type: Experimental/Investigational
Decision: Upheld

The enrollee requested authorization and coverage for bioimpedance-derived physiologic cardiovascular analysis, which allows for remote monitoring of the enrollees implanted cardiovascular device. The enrollee has a history of dyslipidemia, systolic congestive heart failure, status post cardiac resynchronization therapy defibrillator; and atrial fibrillation with rapid ventricular response, resulting in inappropriate automatic implantable cardioverter defibrillator shocks. The enrollee had two prior accessory pathway ablations for atrial fibrillation-related ventricular tachycardia/ventricular fibrillation, and atrioventricular nodal ablation for recurrent ventricular tachycardia arrest. His systolic function has since normalized. The fluid status monitoring feature on the enrollees device previously indicated persistent fluid retention. This, along with transaminitis, has improved. The record indicates an echocardiogram showed normal left ventricular systolic function with a left ventricular ejection fraction of 55-60%. An electrocardiogram showed atrial fibrillation with third-degree atrioventricular block and 100% biventricular pacing. Pacemaker interrogation revealed a biventricular implantable cardioverter-defibrillator. The enrollee had biventricular pacing at 99%, with an estimated battery life greater than five years. There were no significant ventricular events and no implantable cardioverter-defibrillator therapy. Remote monitoring of heart failure enrollees may help in the early detection of acute heart failure decompensation before the onset of symptoms. Appropriate early intervention in these enrollees may reduce heart failure-related hospitalizations. Whether patient management strategies that incorporate device-based hemodynamic sensors have a beneficial impact on outcomes need to be investigated in large clinical trials. This technology has not been shown in large, randomized clinical trials to confer clinical benefit when compared with the conventional management of chronic heart failure. This technology may have a physiologic basis in detecting increased thoracic impedance due to the presence of pulmonary edema from heart failure. However, this technology has not been well-studied enough to identify pitfalls and to establish it as offering proven clinical benefit for patients with suspected heart failure.The enrollees recurrent ventricular tachycardia from his accessory pathway resolved after ablation. At the time of this evaluation, the enrollee had no symptoms of heart failure. Final Result: Three of the three reviewers determined that the requested service is not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in cardiovascular disease 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: Upheld

A thirty-six year-old male was diagnosed with lymphadenitis is requesting authorization of a PET scan.  A CT of the neck was performed which showed a few lymph nodes up to 9mm in size and prominent parotid glands bilaterally.Reviewers Findings:The reviewing physician found that there is little difference between a separately obtained CT scan and PET scan or a combined PET/CT scan and neither a standalone PET or a PET/CT are indicated at this time.  The physician concluded that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for pediatric neurology and/or hematology services at a pediatric tertiary care center. This patients records support a diagnosis of neurofibromatosis 1 (NF1). NF1 is a genetic disorder in which the NF1 gene produces neurofibromin that are unable to function as tumor suppressors, which increases the likelihood of a patient developing neoplasms in the nervous system. This patient has demonstrated increases in neurocutaneous stigmata as well as findings suggestive of changes in myelin. Thus, it is appropriate for the patient to undergo follow-up with a pediatric neurologist at a pediatric tertiary care center with interval neuroimaging based on the providers treatment plan. Although the pediatric neurologist may recommend the services of a hematologist, the medical records provided for review do not support a current indication for hematology services at a pediatric tertiary care center. Therefore, the requested pediatric neurology services at a pediatric tertiary care center are medically necessary for this patient, while the requested hematology services at a pediatric tertiary care center are not medically necessary for this patient. Final Result: The reviewer determined that a portion of the requested services is 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 neurology with special qualification in child 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: Upheld

A 56-year-old male enrollee has requested residential treatment services for treatment of his chemical dependency.  Findings:  The physician reviewer found that the patient did not have any indication of impending withdrawal as evidenced by increased Clinical Institute Withdrawal Assessment scores. He had not attempted outpatient treatment prior to his admission, and there is no indication that his living situation was subversive to sobriety. Furthermore, the records indicate that he had been able to attain and maintain abstinence for prolonged periods of time without substance abuse treatment. During the dates of service at issue, the records do not indicate any behaviors which required containment on a 24-hour basis. The patient was in need of substance abuse treatment. However, residential treatment level of care was not indicated, per American Psychiatric Association guidelines. Based upon the submitted clinical information, the patient could have been safely and effectively treated in a less intensive setting. In this patients case, his treatment needs could have been met in an intensive outpatient setting. Thus, intensive outpatient level of care was medically indicated based upon the submitted medical records. All told, residential treatment services provided were not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 51-year-old woman with long-standing knee pain. She has failed conservative treatment including rest, medication, injections, and physical therapy. The patient underwent an arthroscopy and continues to have pain. She was found to have arthritic changes at the time of the surgery. The patients provider has recommended the patient receive Synvisc injections. The Health Plan indicates there has not been an adequate trial of prescription anti-inflammatories following surgery. The patient is a candidate for Synvisc injections. The submitted records demonstrate the patient has persistent pain despite conservative and surgical attempts to relieve her discomfort. She may eventually require knee replacement. Non-steroidal medication that failed to provide relief preoperatively is not likely to benefit the patient postoperatively. The requested therapy is medically reasonable and appropriate in this clinical setting. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Urgent Care
Decision: Upheld

A 35-year-old male enrollee has requested for emergency ambulance for treatment of his abdominal pain, nausea and vomiting. Findings:  The physician reviewer found that it appears that this patient relied on emergency medical services as a convenient means of transportation to the emergency department for what was a non-necessary visit to the emergency department. His complaints clearly do not meet the definition of an emergency.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee has requested a positron emission tomography (PET) scan for evaluation of  her breast cancer.  Findings:  Three physician reviewers found that aggressive screening for recurrence after successful treatment of early breast cancer, in general, has not been shown to have any effect on survival. The National Comprehensive Cancer Network (NCCN) recommends only four to six months of clinical examinations for the first five years after completion of treatment. Subsequently, the NCCN recommends only annual visits. In terms of imaging, only mammography is recommended. Thus, the requested PET/CT scan for evaluation of this patient who is almost 10 years of recurrence free survival is not likely to be more beneficial for evaluation of her medical condition than standard therapies.