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

The patient has requested reimbursement for intraoperative radiation therapy. Intraoperative radiation therapy is a type of accelerated partial breast irradiation that condenses the entire therapeutic dose into a single fraction, permitting surgery and radiation to be completed in one day. The potential advantages include accurate delivery of radiation therapy directly to the surgical margins and a decreased dose of radiation to skin and subcutaneous tissue. Potential drawbacks include extended time in the operating room, the inability to verify the radiation dosimetry, and the lack of final pathology information at the time of radiation. The National Comprehensive Cancer Network (NCCN) does not support an indication for intraoperative radiation therapy. The NCCN noted that additional studies are needed to determine whether intraoperative radiation therapy has a role in the treatment of breast cancer. All told, the intraoperative radiation was not medically necessary for 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 internal medicine with subspecialty certifications in medical oncology and hematology 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 a 46-year-old female with a history of hypertension, diabetes mellitus, osteoarthritis, and degenerative disc disease. Office notes from 2003 indicate the patient had some limitation in her ability to perform activities such as housework and that certain activities such as walking increased her pain. The patients provider however, also noted that walking was of some benefit to the patient. An office note dated July 2005 states the patient was using a walker. The patient indicates she requires a power-operated vehicle (POV) to assist with ambulation and activities of daily living. The Health Plan has denied authorization and coverage for the requested POV on the basis it is not medically necessary.The submitted documentation does not sufficiently demonstrate that the patient is impaired in performing personal activities of daily living or that she has limited mobility within her home. Although a recent note indicates the patient is using a walker, the patients provider did not document any lower extremity weakness or frequent falls. As such, the patient does not meet medical necessity criteria for authorization of a POV at this time. Therefore, I have determined that the requested POV is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old female enrollee requested Xifaxan (rifaximin) for medical treatment of her small intestinal bacterial overgrowth (SIBO).  Findings:  The physician reviewer found that the submitted documentation established the medical necessity of the medication. The efficacy of Xifaxan in treating non-constipated irritable bowel syndrome (IBS) is well documented in peer-reviewed literature. Accordingly, the drug is a viable treatment option for the population with SIBO.  In this case, SIBO has been objectively demonstrated and the patients longstanding subjective complaints responded to Xifaxan. The drug was appropriately prescribed as a one-time course, is supported by evidence-based literature, and it proved efficacious. Therefore, the medical necessity of the medication at issue has been established in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested excision of excessive thigh skin (15832), breast reduction (19318) and excision of excessive arm skin (15836 for treatment of her medical condition. Findings:  The physician reviewer found that the requested surgical procedures do not meet the criteria for a reconstructive service.  The requested services are not being requested for a congenital defect, developmental abnormality, trauma, tumors, or disease.  Surgical intervention is also not being requested to improve function and does not offer more than a minimal improvement in the appearance of the patient.  It appears as though the proposed surgery is being requested to prevent rashes and lesions that lead to infections.  However, there is a lack of clinical documentation showing that the patient has had any physical examination findings of thigh rashes or lesions leading to an infection.  While the patient was noted to have rashes in the breast and arm areas, a more detailed recent examination and legible photographs are needed to determine the extent and if they require surgical intervention.  All told, the requested excision of excessive thigh skin (15832), breast reduction (19318) and excision of excessive arm skin (15836) are not reconstructive in nature and are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus (HCV). 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), treatment is recommended for all patients with chronic HCV infection, except those with short life expectancies owing to comorbid conditions. Because of the myriad of benefits associated with successful HCV treatment, clinicians should treat HCV-infected patients with antiviral therapy with the goal of achieving a sustained virologic response (SVR), preferably early in the course of their chronic HCV infection before the development of severe liver disease and other complications. Recent reports suggest that initiating therapy in patients with lower stage fibrosis may extend the benefits of SVR. In a long-term follow-up study, 820 patients with Metavir stage F0 or F1 fibrosis confirmed by biopsy were followed for up to 20 years. The 15-year survival rate was statistically significantly better for those who experienced an SVR than for those whose treatment had failed or for those who remained untreated. The study argues for consideration of earlier initiation of treatment (Jezequel, et al). Several other modeling studies suggest a greater mortality benefit if treatment is initiated at stages prior to F3 (vrehus, et al). Therefore, based on AASLD/IDSA guidelines, the requested Harvoni is medically necessary for treatment of the patients HCV. Final Result: The reviewer determined that the requested medication is 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a heavy duty power wheelchair with accessories (E2392, E2386, E2394, K0108, E2623, E2363, and K0739). Moore and colleagues reported that using a 30-degree tilt reduces the incidence of pressure ulcers. Titus and Polger noted that a power tilt wheelchair allows independence in changing body position to address a variety of needs throughout the day. A power tilt-in-space is medically necessary for a power mobility device user to provide pressure relief for pressure injury prevention, comfort and pain relief, and posture realignment. In this case, the patient has paraplegia with neurologically intact upper extremities, but is unable to perform pressure relieving maneuvers independently. He has stage 2 sacral pressure ulcers. The patients wheelchair is over ten years old and the power tilt-in-space functionality is not working. Given that repair of the power tilt functionality, including the actuator, hydraulic cylinder, and other parts, is medically necessary for the treatment of his pressure ulcers, and prevention of future pressure injuries, K0108 is medically indicated. As the battery is not holding its charge, battery replacement, E2363 is medically indicated to prevent loss of power functionality for mobility and power tilt. E2392 is medically indicated as the tires are documented to be worn. E2386 and E2394 are medically indicated as the wheel drive and assemblies are documented to be damaged. Given that these repairs require technician labor, K0739 is medically indicated. As there is no documentation that an attempt has been made to reinflate or repair the patients ROHO cushion, a replacement seat cushion, E2623, is not medically indicated. Therefore, a heavy duty power wheelchair with accessories (E2392, E2386, E2394, K0108, and K0739) is medically necessary for the treatment of this patient. Per the submitted documentation, E2623 is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested equipment is partially medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be partially overturned.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: Overturned

The patient is a 52-year-old female with type II diabetes mellitus, diagnosed about nine years ago. In July 2005 she was on Glipizide 10mg twice per day and Avandia 4mg twice per day and her HgbA1C was 9.8%. The record indicates the patient does not tolerate Metformin due to diarrhea, and she was started on Lantus insulin at 18 units. The patients weight was reported as 240 pounds. In December of 2005 her HgbA1C decreased to 8.5% and she had a weight loss of five pounds. At that time, she was started on Byetta 5mcg twice per day. In March 2006 the patients HgbA1C had decreased further to 7.1% and she lost an additional three pounds. In June 2006 her HgbA1C was down to 6.7%.  The patient has requested reimbursement and continued authorization and coverage for Byetta. The Health Plan denied her request based upon a determination that the medication was/is not medically necessary.The patient is a type II diabetic who is overweight and was previously managed with insulin injections and oral Glipizide and Avandia. After adding Byetta to her regimen in December 2005 her HgbA1C dropped from 8.5% to 6.7% and she has lost three pounds.  The FDA approval of Byetta is limited to patients with type II diabetes who take sulfonylurea and/or Metformin only because the clinical trials involved those two medications. Current studies of Byetta in combination with thiazolidinediones (TZDs) such as Avandia have been submitted to the FDA and are awaiting approval.  Additional studies of Byetta in combination with insulin are also being conducted.  Byetta has been shown to be effective for patients with type II diabetes who are insulin resistant and have beta cell reserve. This patient is within that class of patients and responded well to treatment with Byetta as demonstrated by her weight loss and improved HgbA1C. Many endocrinologists have recognized the benefit of Byetta for patients like this one and it is widely prescribed. The patient has improved her diabetic control with the addition of Byetta and continued treatment may help to prevent long-term diabetic complications. Therefore, I have determined the medication at issue was/is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lyrica 300 mg three times per day. Findings:  The physician reviewer found that In the medical literature, a study reported that the use of Lyrica has shown favorable outcome for treatment of sciatica. Another studynoted that Lyrica has demonstrated benefit for various neuropathic pain conditions alone and in combination with other pharmacologic therapies. One more study found that Lyrica demonstrated improvement in pain related to radiculopathy in sciatic distribution similar to gabapentin. However, higher dosing at 900 mg per day is not recommended. Further, there are no circumstances in this case that suggest dosing beyond that approved by the U.S. Food and Drug Administration (FDA) would be appropriate. Thus, the requested dosage of Lyrica 300 mg three times per day is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested dosage 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 neurology with sub-specialty certification in pain 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 50-year-old female enrollee requested authorization and coverage of six injections of Imitrex per month. The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollees migraines headaches. 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

The patient is a 50-year-old female who is status post gastric bypass surgery in 2003 with a weight loss of over 100 pounds.  Her weight is apparently stable at 148 pounds.  The patient complains of skin rashes, body odor and back pain due to her excess abdominal skin. The record includes several entries regarding rashes and infections in the area of the umbilicus.  In December 2005 her provider noted she also has another infection in the umbilicus and still will use her bactroban for this. The September 2005 office note states recurrent infection of umbilicus and describes the area as wet, red, tender, and slightly edematous. The May 2005 office note reflects her providers observations that skin folds in, around and in umbilicus get(s) itchy and red. Lotrimin usually helps and that there was unusually redundant skin about umbilicus, with what appears to be an erythematous, slightly scaly rash inside it.  The patient was examined by a plastic surgeon in March 2005 who noted there is no evidence of a rash in the intertriginous area on examination today.In making a determination as to whether the requested surgery is cosmetic or medically necessary, it is appropriate to consider the criteria set forth in the American Society of Plastic and Reconstructive Surgeons position papers for Abdominoplasty and Treatment of Skin Redundancy Following Massive Weight Loss. The ASPRS requires uncontrollable intertrigo of the skin folds of the panniculus.  Neither recurrent infection around the umbilicus or the downward level of the pannus (bottom edge) as it relates to the symphasis pubis are inclusion criteria for medically necessary abdominoplasty or panniculectomy.    Although the patient did have recurrent infection around the umbilicus, a review of the office notes provided did not reveal any evidence of intertrigo in the sub-pannus skin (the skin between the underside of the pannus and the native mons tissue).  The level of her pannus is not a factor in the determination.  The patient lists numerous complaints in her appeal letter, but the record did not include corresponding documentation from her providers to clinically support these complaints. Based upon the information set forth above, I have determined the requested surgery is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 42-year-old female with relapsing remitting multiple sclerosis since 1998. Because of gait difficulties affecting her right leg (hemiparesis, weakness, and decreased tone), the patient has requested body weight support treadmill therapy. The Health Plan has denied authorization for body weight support treadmill therapy on the basis that it is not medically necessary for treatment of the patients multiple sclerosis.Body weight support treadmill therapy is essential for patients such as this patient. The therapy avoids major stress on the affected limb and prevents fatigue of the limb. Fatigue during therapy is to be avoided since it may aggravate the condition. Body weight support therapy is medically indicated for this patient until muscle power and tone improve in the right leg allowing the patient to ambulate more normally and with less stress. 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intraosseous ablation of the basivertebral nerve with the Intracept procedure. The guidelines published from the International Society for the Advancement of Spine Surgery noted that intraosseous basivertebral nerve ablation for the treatment of chronic low back pain is a treatment option for patients with clinical and radiologic findings supporting a vertebrogenic source of back pain. Randomized controlled trials have reported statistically significant pain scores and functional improvements over a two year period with use of the Intracept procedure (Khalil, et al.; Lorio, et al.; Fischgrund, et al.). This patients clinical and radiologic findings of Modic type changes at L5 support a vertebrogenic cause of back pain. The patient has not experienced substantial relief from comprehensive and multimodal treatment options. Chronic use of opioids is not indicated for the treatment of chronic low back pain. Radiofrequency ablation of the basivertebral nerve is the indicated as the next step in the treatment algorithm and is likely to provide functional relief to the patient. Therefore, the requested intraosseous ablation of the basivertebral nerve with the Intracept procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested intraosseous ablation of the basivertebral nerve with the Intracept procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in anesthesiology with subspecialty certification in pain management 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: Experimental/Investigational
Decision: Upheld

A male enrollee requested prostate artery embolization for medical treatment of his benign prostatic hyperplasia.   Findings:  Two physician reviewers found that there is a paucity of peer-reviewed medical literature supporting the long-term safety and efficacy of prostatic arterial embolization to treat symptomatic benign prostatic hyperplasia. Limited international studies have demonstrated possible short-term benefits. However, there is also a lack of comparative studies evaluating prostate artery embolization as compared to other methods such as TURP. All told, the requested prostate artery embolization is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Embeda for treatment of her medical condition.  Findings:  The physician reviewer found that based on the documentation submitted for review, the medical necessity for Embeda has been established in this clinical setting. Embeda has been noted to provide adequate analgesia without side effects and is comparable to Avinza. In addition, the patient is at low risk for opioid abuse, and she has tried and failed other morphine alternatives. Since Avinza was discontinued, she has tried and failed Kadian and two other MS Contin formulations. In addition, she has tried and failed fentanyl patch, Opana and Oxycodone.  Embeda is a long acting morphine agent which has provided the patient with adequate pain relief. Given that she has exhausted other morphine formulations, Embeda was and is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the medication at issue was and 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 anesthesiology with sub-certification in pain 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.