Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old male enrollee has requested Ozurdex intraocular implant for treatment of his chronic macular edema.  Findings:  Three physician reviewers found that per the submitted documentation, this patient has refractory macular edema, and the only treatment shown to be efficacious is treatment with high-dose steroids via Ozurdex intraocular implant.  When the dose wears off, the macular edema recurs.  The provider has recommended Retisert intraocular implant, and this provides the same treatment over a longer duration.  In this patients case, there are limited available treatment options.  Steroids are the treatment of choice for macular edema, and this patients condition has been shown to be refractory to all treatments other than high-dose intravitreal steroids.  All told, Ozurdex intraocular implant provided on the said date and future treatment with Retisert intraocular implant were and are likely to be more beneficial than other treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old female enrollee requested bariatric surgery for medical treatment of her morbid obesity.  Findings:  The physician reviewer found that the National Institute of Health (NIH) consensus guidelines recommended that bariatric surgery should be considered for patients who have a BMI greater than 40, or a BMI greater than 35 in association with major comorbidities such as severe sleep apnea, Pickwickian syndrome, and obesity related comorbidities. According to the documentation submitted for review, the patient presents with clinically severe obesity with a BMI of 41 and comorbid conditions that include hypertension and back pain. Based on the documentation submitted for review, the patient meets the accepted criteria for bariatric surgery. As such, the requested procedure is medically necessary for the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for liposuction of the trunk (CPT 15877) and neck (CPT 15876). This patient presents with evidence of severe lipodystrophy of the neck and back as a likely complication of her treatment for congenital HIV. Liposuction is supported in the medical literature for use to treat deformities in a reconstructive fashion, as is the case for this patient. Colleagues noted that the standard treatment for HIV is a combination of protease inhibitors and reverse transcriptase inhibitors. Although these medications have greatly improved morbidity and mortality rates in HIV patients, they have also been found to cause significant side effects, most commonly hypertriglyceridemia in approximately three-quarters of patients, hyperglycemia, insulin resistance, and abnormal fat distribution. Colleagues reported that suction-assisted liposuction is appropriate to treat the deformities causes by HIV treatment. Given this support, the requested liposuction of the trunk (CPT 15877) and neck (CPT 15876) 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 plastic 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: Overturned

The parent of a 5-year-old male enrollee has requested applied behavioral analysis (ABA) therapy at a frequency of 40 hours per week and supervision at a frequency of 8 hours per month for treatment of the enrollees autism.  Findings:  The physician reviewer found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder. Treatments based on operant principles of learning are more effective in reducing maladaptive behaviors than alternative treatments. A paper by Warren and colleagues reviewed 34 studies of early intervention in autism and concluded that studies of Lovaas-based approaches as well as early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills (Warren, et al.). Treatment intensity may play an important role and ABA therapy must be implemented at a sufficient intensity in order to provide optimal outcomes (Kelley, et al. and Granpeesheh, et al.). Although the most significant gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years of therapy (Sallows, et al.). The goals for older children are often to identify and remediate particular deficits, including non-compliance, tantrums and self-stimulatory behaviors, such is the case with this patient; and to improve his overall adaptive and communication skills. Therefore, it is medically necessary that the patient continue to receive ABA therapy at the recommended frequency of 40 hours per week, with 8 hours per week of supervision.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xeljanz XR tablets. Findings: The U.S. Food and Drug Administration (FDA) approves the use of Xeljanz for the treatment of ulcerative colitis. A study found that patients with moderately to severely active ulcerative colitis treated with tofacitinib were more likely to have clinical response and remission than those receiving a placebo. Another study noted that Janus kinase (JAK) inhibitors, such as tofacitinib, are designed to selectively target the activity of specific JAKs and to offer a targeted mechanism of action without risk of immunogenicity. Other guidelines for the management of moderate to severe ulcerative colitis noted, In adult outpatients with moderate to severe UC who have previously been exposed to infliximab, particularly those with primary nonresponse, suggest using ustekinumab or tofacitinib rather than vedolizumab or adalimumab for induction of remission. In this case, the patient did not respond to infliximab, and has tried and failed several other therapies, including anti-TNFs. Given the current medical literature and the providers recommendation, the requested medication is medically indicated. Therefore, Xeljanz tablets 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested inpatient rehabilitation services for medical treatment of his behavioral health condition. Findings:  The physician reviewer found that according to the documentation submitted for review, the patient presented with moderate withdrawal symptoms. Subsequently, the patient did not require 24-hour supervision in an inpatient rehabilitation facility. The patients treatment and medication changes could have been rendered at a lower level of care. Based on the medical literature cited above and the documentation submitted for review, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old female enrollee has requested continued adult psychiatric acute inpatient treatments including electroconvulsive therapy (ECT) for the treatment of her major depressive disorder, recurrent, severe, without psychosis. Findings:  The physician reviewer found that this patient is severely ill. Her clinical depression is severe. She has harbored suicidal thoughts for a considerable period of time. She has a specific plan and the means to accomplish the act. It is true that she improved around the time ECT began, but her history is one in which the degree of her suicidal thinking vacillated.  Her improvement could not be interpreted as substantive. Although she denied suicidal thinking during the days after ECT began, her history was one in which it was logical to expect these thoughts to resurface. Her treating physician indicated that ECT could not be given as an outpatient, and he felt there was a reasonable clinical possibility that her suicidal thinking might return. This concern was increased with knowledge that the patients mother has died. Her plan to commit suicide upon the death of her husband must also be reconsidered given the death of her mother. It would have been extremely unsafe to discharge this patient to any lesser level of care. A full ECT series within the acute psychiatric facility is medically indicated and appropriate. It was and is medically necessary that this patient remain in the acute care facility.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla for treatment of the enrollees moderate to severe plaque psoriasis. Findings:  The physician reviewer found that this patient has reportedly tried and failed treatment with topical steroids, methotrexate and Enbrel. As noted in the medical literature, Enbrel and Humira are within the same biologic class with the same mechanism of action. As the patient has already failed a six month course of treatment with Enbrel, it is not reasonable to require that he also fail therapy with Humira prior to coverage of Otezla. In addition, Otezla is a U.S. Food and Drug Administration (FDA) approved oral medication for the treatment of psoriasis. Otezla does not require routine laboratory monitoring due to its safety profile. Given that the patient has already failed two preferred systemic agents for psoriasis, the request for Otezla is supported as medically necessary for treatment of the patients plaque psoriasis. 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 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: An enrollee has requested reimbursement for the Prometheus laboratory testing. Findings:  Three physician reviewers found Based on the current peer-reviewed medical literature, the Anser IFX test has not been demonstrated to be safe and effective for the management of Crohns disease. The presence of antibodies does not result in reactions to infliximab or loss of response to infliximab, nor have threshold levels been established. Furthermore, studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response. The only randomized trial comparing management of failure with dose intensification versus antibody/drug level-guided testing found no significant difference in clinical effectiveness when testing was used to guide therapy. Accordingly, the Prometheus laboratory testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the Prometheus laboratory testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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

A 21-year-old male enrollee has requested residential treatment for treatment of his substance use disorder. Findings:  The physician reviewer found that the clinical practice guidelines reserve the RTC level of care for patients who present with a severe illness with the need for intensive, 24-hour services. The American Society of Addiction Medicine (ASAM) recommends treatment in a 24-hour structured setting when treatable psychiatric, medical symptoms or destructive behaviors exist that would likely interfere with the patient maintaining abstinence. In addition, there should be evidence of functional impairment in at least two domains including work/school, activities of daily living, family/interpersonal, and physical health. This patient did not appear to meet the severity of illness as noted above. The intensity of service criteria does not appear to be met as he did not require the 24-hour medical supervision provided at that level of care. Thus, based on the patients presenting symptoms and the documented admission criteria, he could have been safely and adequately treated in a less restricted environment, which would have been intensive outpatient therapy. Therefore, the RTC services rendered during the timeframe at issue were not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni for 12 weeks for treatment of the enrollees hepatitis C virus.  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 except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The 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: Physician reviewer number one 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

A 64-year-old female enrollee has requested bronchial thermoplasty for treatment of her severe persistent asthma with exacerbation.  Findings:  Two physician reviewers found that this patient has severe asthma and has been treated with first-line therapies without substantial benefit. The records indicate the patient continues to have exacerbations requiring steroid therapy. For these reasons, this patient is an appropriate candidate for bronchial thermoplasty, which has been proven to be effective in patients with severe persistent asthma in reducing exacerbations, the need for steroids, and hospitalizations. All told, the requested procedure is likely to provide superior benefit when compared with standard modalities.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested Synvisc One (hyaluronic acid) injection for treatment of her right knee osteoarthritis.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested Synvisc One injection (viscosupplementation). The patient has both an MRI and arthroscopically documented degenerative osteoarthritis of the knee joint with the MRI showing marrow edema in the femoral condyle. There have been carefully conducted double-blinded studies which do not document that viscosupplementation has any meaningful benefit in this clinical setting. In addition, there is a recognized incidence of aseptic inflammatory reaction due to allergic response. There is also a risk of iatrogenic infection. A recent metaanalysis of the efficacy of viscosupplementation has been performed. This study concluded after review of a total of 89 trials, (involving 12,667 adults) that patients with knee osteoarthritis viscosupplementation are associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse events (Rutjes, et al.). In conclusion, the medical necessity of the requested therapy has not been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral hip replacement surgery sooner than three months for treatment of the enrollees hip pain. Findings:  The physician reviewer found that the current, evidence-based, medical guidelines recommend total hip arthroplasty when all reasonable conservative measures have been exhausted and other reasonable surgical options have been seriously considered or implemented. Criteria include exercise therapy with supervised physical therapy and/or home rehabilitation exercises and medications, which unless contraindicated, include non-steroidal anti-inflammatory drugs or steroid injections. Subjective findings should include limited range of motion, or night-time joint pain, or no pain relief with conservative care. Objective findings should include over 50 years of age and body mass index less than 35 kg/m2.  Additionally, imaging findings of osteoarthritis on standing x-rays or arthroscopy are required. This patient presents with a history of chronic bilateral hip pain, worsening over the past year. The severity of his pain was impacting his activities of daily living.  There were no specific hip examination findings documented.  There is imaging evidence of severe left hip and mild to moderate right hip osteoarthritis.  Conservative treatment was documented to include opioid pain medications and nonsteroidal anti-inflammatory drugs. Evidence-based medical guideline and peer-reviewed literature guidelines have been met to support the medical necessity of total hip replacement. The Health Plan anticipated scheduling bilateral total hip replacements in approximately three months, but the patient has requested surgery sooner due to pain.  However, there is no current documentation that the patients pain medication or other conservative treatment has failed to provide adequate pain management to support a request for sooner surgery. 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 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 42-year-old female enrollee requested authorization and coverage of a cervical and thoracic magnetic resonance imaging (MRI) study. The Health Plan denied the request indicating that the requested MRI is not medically necessary for evaluation of the enrollees back pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested MRI is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Epclusa 400100 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 except those with life expectancy less than 12 months due to non-liver-related conditions, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as first-line therapy for treatment-naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate (98%) with this regimen. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Epclusa 400 mg  100 mg for 12 weeks is medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A fifty-seven year-old male with type 2 diabetes mellitus is requesting authorization of Byetta. The provider submitted a request for authorization of Byetta two weeks later noting that the patient had taken Glucophage, Actos and glyburide with poor results.Reviewers Findings:  The reviewing physician found that had glyburide been discontinued without starting Byetta, the patient might still have lost weight and maintained good blood glucose control on Actos and metformin alone.  The reviewing physician found that the Health Plan denial should be upheld.