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

The enrollee is requesting authorization and coverage for tab-style adult diapers and bed pads. The enrollee has a history of diabetes mellitus, and incontinence. A progress note showed the enrollee had a history of mixed incontinence, with five or more events per day. She has tried Oxybutynin without improvement and has tried one session of pelvic floor physical therapy. The physicians assessment was stress incontinence versus overflow incontinence, and urinary retention. This enrollee was evaluated by a urogynecologist. He advised pelvic floor exercises, physical therapy, timed voiding, and urge suppression. There was no advice given regarding the use of absorbent bladder protection pads. Medical records do not demonstrate a chronic pathological condition causing either her suspected stress or overflow incontinence. Studies have shown that extended use of adult diapers can exacerbate incontinence instead of improve it, and that refraining from the use of these products may alleviate or resolve incontinence.Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in family practice and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 38-year-old female enrollee has requested uvulopalatopharyngoplasty, tonsillectomy and partial glossectomy for the treatment of her obstructive sleep apnea syndrome. Findings:  The physician reviewer found that the parameters for polysomnographic criteria in establishing the presence of significant OSA and candidacy for use of CPAP or for surgical intervention are routinely stated to be AHI greater than or equal to 15 or AHI greater than or equal to 5 and less than or equal to 14 with documentation of daytime sleepiness, impaired cognition, mood disorder or insomnia, hypertension, presence of ischemic heart disease or history of a stroke.  Documentation of daytime sleepiness is generally done through the use of the Epworth scale questionnaire.  The patient had an Epworth score of one.  In standard practice, an Epworth score of less than 8 is considered normal.  The patient does not meet current standard of care criteria for medical necessity in terms of surgical intervention for OSA.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A parent of an enrollee has requested authorization and coverage for Nutropin AQ Nuspin.Findings: The U.S. Food and Drug Administration (FDA) has approved somatotropin to treat idiopathic short stature (ISS), defined as standing height below -2.25 SDs without identifiable cause. Standard of pediatric endocrine care for suspected growth disorders includes brain magnetic resonance imaging (MRI) with and without gadolinium contrast and standard provocative testing for endogenous growth hormone release. In this case, the patient has not met the FDA-approved indications or generally accepted indications for somatotropin. The patient displays normal height and appropriate growth velocity for mid-puberty. Additionally, the patients pubertal timing, pubertal tempo, and predicted adult height are consistent with her familial patterns. Moreover, there are no records of brain magnetic resonance imaging or any standard provocative test for endogenous growth hormone release. Therefore, Nutropin AQ NuSpin is not medically necessary for the treatment of the patients medical condition. 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of the enrollees hepatitis C.  Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Viekira Pak or Harvoni.  Both medications are U.S. Food and Drug Administration (FDA) approved for patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. There is a lack of head-to-head direct comparison trials showing that Harvoni is superior to Viekira Pak.  In this patients case, no medical contraindication to Viekira Pak/ribavirin was documented.  Although hepatitis C treatment is needed in this case, Harvoni is not supported over Viekira Pak. The Health Plan has offered Viekira Pak as an alternative. For these reasons, the requested treatment with Harvoni for eight weeks is not 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested stereotactic radiosurgery (SRS) for treatment of his cluster headaches.  Two physician reviewers found that the submitted records do not adequately define the patients headache syndrome. There is a lack of documentation of the duration, frequency and severity of the patients headaches. Additionally, the patients medication attempts are not well documented, as details regarding the dose, duration, combination of medications trialed and treatment response are not included in the submitted records. As such, it has not been established that the patient exhausted standard therapies prior to pursuing treatment with SRS. Given the lack of controlled studies supporting the safety and long term benefit of SRS for the management of cluster headaches, there is insufficient evidence demonstrating that SRS was likely to have been more beneficial for treatment of the patients medical condition than available standard therapies in this setting, which based upon the records provided, do not appear to have been exhausted.  Final Result:  Two reviewers determined that the services at issue were 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: All three reviewers are board certified in neurology 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: The patient has requested reimbursement for Ocrevus (ocrelizumab). Findings: The U.S. Food and Drug Administration (FDA) approves the use of ocrelizumab (brand name Ocrevus) for the treatment of patients with relapsing or primary progressive forms of multiple sclerosis (MS). The American Academy of Neurology practice guideline recommendations for disease modifying therapy (DMT) for adults with multiple sclerosis include offering DMTs to patients with relapsing forms of MS with recent clinical relapses or magnetic resonance imaging (MRI) activity. A study notes that in two phase III trials among patients with relapsing MS, ocrelizumab was associated with lower rates of disease activity and progression than interferon beta-1a over a period of 96 weeks. Another study notes that the results of a systemic literature search suggested that ocrelizumab has an efficacy superior to or comparable with all other currently approved DMTs across all endpoints analyzed, and a similar safety profile, indicating that it offers a valuable package for the treatment of patients with relapsing MS. In this case, the patient has a diagnosis of relapsing remitting MS, presenting with breakthrough disease activity and active lesions on MRI despite therapy with Gilenya, a DMT. In this clinical setting, given trying a different medication with a different mechanism or efficacy profile may be beneficial and as current medical literature shows ocrelizumab has an efficacy superior to or comparable with all other currently approved DMTs, the requested medication is medically indicated. Therefore, Ocrevus (ocrelizumab) was 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Xyosted 75 mg/0.5 ml auto injector. Testosterone replacement therapy for hypogonadism may be indicated based on laboratory results, when two values show a deficiency in free testosterone when measured against normal values by 11 a.m. on each draw. Ongoing treatment of hypogonadism would be indicated by low or low-normal values prior to routine supplementation. In this case, given that the submitted laboratory testing showed normal testosterone values of free testosterone within 35-155 pg/mL and total testosterone within 250-1,100 ng/dL, the medication at issue was not and is not medically indicated. Therefore, Xyosted 75 mg/0.5 ml auto injector was not and is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was not and 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 urology 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 female enrollee has requested paraesophageal hernia repair surgery for treatment of the enrollees paraesophageal hernia.  Findings:  The physician reviewer found that submitted documentation and relevant literature demonstrates the medical necessity of the requested procedure. In this case, the patient has paraesophageal hernia and organoaxial volvulus documented on chest x-ray. The patients shortness of breath and wheezing is likely due to her paraesophageal hernia as patients in this clinical setting often suffer from chronic aspiration which causes progressive pulmonary damage and shortness of breath. The patients shortness of breath precludes exercise which prevents her from managing her weight loss effectively. As such, the surgical repair of the paraesophageal hernia will likely improver her pulmonary function and her shortness of breath and prevent the potential of emergency repair of acute volvulus. All told, based on the medical records submitted for review and the peer-reviewed literature, the requested procedure is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential mental health and eating disorder treatment program services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. Around the dates in question, the patient had made progress in his eating disorder. The patient was motivated to continue treatment and was actively participating in treatment. The patient was medically stable and did not require 24-hour supervision. Given that the patient was not medically compromised, there is data supporting that treatment in a residential treatment center setting does not provide advantages over outpatient management. It is the standard of care to treat patients in the least restrictive environment possible. Per the records, this patient required treatment for his anorexia nervosa, depression, and anxiety. However, he could have been safely and effectively treated in a less restrictive environment. Therefore, residential mental health and eating disorder treatment program services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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: Overturned

The parent of an eight-year-old male enrollee has requested cognitive skills therapy for the treatment of the enrollees Aspergers disorder. Findings:  Two physician reviewers found that this patient has a diagnosis of Aspergers disorder with impairment in social functioning, impulse control, attention focusing and encopresis. Aspergers disorder and attention deficit/hyperactivity disorder are complex neurodevelopmental disorders that require various treatment modalities to maximize functioning and to address core difficulties. A trial on a psychostimulant was unsuccessful. Cognitive skills therapy was utilized to target multiple areas of impairment. This is a widely used and accepted approach in the community for the treatment of core symptoms of autism spectrum disorder. This approach is consistent with the American Academy of Child and Adolescent Psychiatry guidelines and the current literature.
Appeal type: Experimental/Investigational
Decision: Upheld

The enrollee requested authorization and coverage for genetic testing. The enrollee has Hashimotos thyroiditis, hypothyroidism, ulcerative colitis, high body mass index, and hyperlipidemia. She is on hormone replacement therapy. She has a family history of blood clots, coronary artery disease and respiratory failure. Literature reports the genetic status of at-risk family members without symptoms can be established with genetic testing, but the indications for testing of at-risk family members are unresolved. Without evidence that early identification of the Leiden variant leads to interventions that can reduce disease symptoms or death, decisions regarding testing should be made on an individual basis. Most guidelines consider such testing justified only for relatives of the first family member noted to have a lack of natural anticoagulants, or with multiple abnormalities.Final Result: Three of the three reviewers determined that the requested services are 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 Pain Management 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 63-year-old female enrollee, with high-grade endometrial cancer, has requested authorization for a full-body PET scan. Findings:  The physician reviewer found that the previous Centers for Medicare and Medicaid Services (CMS) indications for PET scans did not include uterine cancer. However, the National Oncologic PET Registry (NOPR) was developed in response to a CMS proposal to expand coverage for PET scans to include cancers and other indications not previously eligible for Medicare reimbursement. The diagnosis, staging, restaging, and monitoring of uterine cancer are now listed as indications for PET scan. The sensitivity and specificity for PET in endometrial cancer are high; 83-100% sensitivity and 78-99% specificity. PET combined with CT or MRI has been shown to be more sensitive than CT or MRI alone in overall lesion detection and in detection of pelvic nodal or extra pelvic metastases.
Appeal type: Experimental/Investigational
Decision: Overturned

A 38-year-old male enrollee requested authorization and coverage of autologous stem cell transplantation. The Health Plan denied the request indicating that the requested therapy is considered experimental for the treatment of the enrollees Crohns disease.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested therapy is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. One  physician reviewer concluded that the requested therapy is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) Chantix 0.5 mg tablet, and (2) Chantix 1 mg tablet. Mills and colleagues compared the efficacy of nicotine replacement and varenicline (Chantix), and found that all therapies were effective in smoking cessation. Only varenicline demonstrated benefit over standard nicotine replacement therapy. In this case, the patient is a documented long-term smoker who would benefit from smoking cessation therapy. Chantix is medically appropriate in this patients case. Therefore Chantix 0.5 mg tablet, and (2) Chantix 1 mg tablet are 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 family 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: Upheld

A 26-year-old female enrollee has requested a bariatric surgical procedure, laparoscopic gastric banding (lap band) for the treatment of her medical condition.  Findings:  The physician reviewer found that obesity has to be considered a multi-factorial chronic disease which develops from an interaction of genetic and environmental factors. This eventually leads to serious co-morbidities. At the present time, the patients only complaint is lower back pain.  The ASBS Consensus Conference states that class I and II obese individuals treated conservatively can achieve acceptable results in 10-40% of the cases. The degree of success depends greatly on the weight loss program design, which should include proper supervision with intense behavioral modification and exercise along with possible use of medication. Long-term weight loss is very difficult to maintain, and the majority of patients ultimately present as candidates for bariatric surgery.  However, the patient is young and does not have any comorbidities demonstrating the need for surgery. Based upon the information provided, this patient does not meet nationally accepted criteria for consideration of weight loss surgery and should continue attempts at conservative weight loss.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for left knee Orthovisc (J7324) injections weekly for four doses. Findings:  The physician reviewer found that per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of osteoarthritis of the left knee. The patient has tried and failed conservative treatment, including a corticosteroid injection that only provided slight relief, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, left knee Orthovisc (J7324) injections weekly for four doses are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old male enrollee requested authorization and coverage of the medication Buprenex. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees migraine headaches.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.