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

A 39-year-old female enrollee has requested physical therapy for treatment of her lumbosacral scoliosis and back pain.   Findings:  The physician reviewer found that a review of the relevant medical literature reveals that exercise therapy has been determined to be effective at reducing pain and functional limitations in the treatment of chronic low back pain. Further, the clinical trials suggest that post-treatment exercise therapy may decrease the recurrence of back pain. According to this patients documentation, she has had intermittent low back pain for a few years with a pain level ranging between 5 and 8 out of 10. She reports that she has increased back pain with bending, prolonged sitting or standing. The provider documented the patient has tenderness in her back on evaluation but found no focal neurological deficit. Consistent with the recommendations, physical therapy is an effective treatment of chronic low back pain and this patient has functional impairments that can be expected to substantially improve with the treatment (Hayden, et al. and Choi, et al.). For these reasons, the requested physical therapy is clinically indicated and appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned

A 76-year-old male enrollee requested authorization and coverage of the medication bosentan for the treatment of pulmonary hypertension. The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that the medication bosentan  is likely to be more beneficial for treatment of the enrollees pulmonary hypertension than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization overturned the health plans denial.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested genetic testing (Foundation One) and genetic testing (Guardant Molecular Profiling) for evaluation of her medical condition.  Findings:  Two physician reviewers found that in this case, the patients tumor is rare and so the medical literature has small case series describing chemotherapy responsiveness, resistance, and in one case a good result from high dose chemotherapy followed by autologous stem cell transplant. As such, Foundation One testing was indicated and likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. However, Guardant Molecular Profiling is not the standard of care in this clinical setting. As such, the Guardant Molecular Profiling was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that that a portion of the services at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications:   One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  Two reviewers are board certified in medical oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested Harvoni (ledipasvir/sofosbuvir) 90/400 mg for medical treatment of her hepatitis C virus.  Findings:  Three physician reviewers found that review of the submitted documentation establishes the medical necessity of the requested medication. According to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. AASLD and IDSA guidelines further state, Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons.  Therefore, the requested Harvoni medication is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old female has requested a nerve conduction study and EMG study for evaluation of her bilateral hand pain and numbness.  Findings:  The physician reviewer found that this patient has multiple possible causes for her upper limb pain and numbness.  She has failed conservative treatment with nonsteroidal anti-inflammatory medications and wrist splinting.  It is imperative that the cause of her pain be accurately diagnosed, or her pain will persist.  An EMG and nerve conduction study will help determine if the cause of her symptoms is median neuropathy, cervical radiculopathy or fibromyalgia.  In this clinical scenario, the requested services are medically necessary given the patients continued pain. All told, based upon the submitted documentation, a nerve conduction study and EMG study are medically indicated for evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female enrollee has requested testing for evaluation of her medical condition. Findings:  The physician reviewer found that Review of the submitted clinical evidence demonstrates that this patient has had a variety of symptoms including cramping and muscle pain. Myotonic dystrophy has been considered in the diagnosis. The patients physical exam and EMG have not revealed any muscle weakness or myotonic activity. Per a literature review, myotonic dystrophy type 2 (DM2) is characterized by myotonia (90% of affected individuals) and muscle dysfunction (weakness, pain, and stiffness) (82%), and less commonly by cardiac conduction defects, iridescent posterior subcapsular cataracts, insulin insensitive type 2 diabetes mellitus, and testicular failure. Although myotonia (involuntary muscle contraction with delayed relaxation) has been reported during the first decade, onset is typically in the third decade, most commonly with fluctuating or episodic muscle pain that can be debilitating and weakness of the neck flexors and finger flexors. Subsequently, weakness occurs in the elbow extensors and the hip flexors and extensors. Facial weakness and weakness of the ankle dorsiflexors are less common.The literature also reveals that absent or minimal myotonic discharges on EMG do not exclude myotonic dystrophy type 2. This patients symptoms and exam could potentially represent early features of myotonic dystrophy, and knowledge of this diagnosis would impact her long-term care. Consequently, genetic testing for myotonic dystrophy type 2 is relevant and medically necessary in this case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for photorefractive keratectomy (PRK). Findings:  The physician reviewer found that this patients records document a history of lattice corneal dystrophy. The provider has recommended treatment with PRK. Lattice corneal dystrophy leads to deposition of amyloid in the cornea causing blurriness and loss of vision. In this clinical setting, the medical literature supports treatment with excimer laser removal of the corneal opacities and stroma. The requested PRK procedure will remove the corneal opacities that are interfering with the patients vision. Given this support, the requested PRK is medically necessary for treatment of this patient. Moreover, the requested PRK is reconstructive in nature for this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. The presence of lattice corneal dystrophy is an abnormal structure of the body and the PRK is being performed to improve the patients function. For these reasons, the requested PRK is medically necessary and reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in ophthalmology 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: An enrollee has requested authorization and coverage for Lovaza for treatment of the enrollees hypercholesterolemia. Findings:  The physician reviewer found that current evidence supports that elevated triglyceride levels are independently associated with cardiovascular risk. The medical records provided does not document a triglyceride level of more than 500 mg/dL while off medication.  However, there is documentation of hypertriglyceridemia of more than 200 mg/dl and documentation of intolerance to others form of cholesterol medication. In this clinical setting of known coronary disease and documented intolerance to most lipid therapies it is reasonable and appropriate to treat the patient with Lovaza even when only moderate hypertriglyceridemia (200 to 500 mg/dl) is present if patients are intolerant to statin therapy and other targeted therapies to reduce triglyceride levels such as with 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 cardiovascular disease 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: An enrollee has requested authorization and coverage for Taltz 80 mg autoinjector. This patient has been stable on Taltz with good improvement in her symptoms for the past year. Taltz is U.S. Food and Drug Administration (FDA) approved for the treatment of psoriasis and has shown good efficacy in the treatment of nail psoriasis. Given that this patient has experienced satisfactory results with Taltz, the risk of flare in stopping to switch to another agent is not appropriate. As treatment with Taltz has stabilized this patients medical condition, the requested Taltz 80 mg autoinjector is medically necessary. 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oxycodone 30 mg. With regard to the treatment of chronic low back pain with opioid therapy, a review concluded that there is evidence of short-term efficacy (moderate for pain and small for function) of opioids to treat chronic low back pain (CLBP) compared with placebo. The effectiveness and safety of long-term opioid therapy for treatment of CLBP remains unproven. Similarly, a review by Shaheed and colleagues also determined that for patients with chronic low back pain who tolerate the medicine, opioid analgesics provide modest short-term pain relief but the effect is not likely to be clinically important within guideline recommended doses. Evidence on long-term efficacy is lacking. An outcome study on the effects of opioid therapy for lumbar disc herniation established that patients who were treated with opioids had significantly worse baseline pain and quality of life. At final follow-up, there was no long term difference in outcome associated with opioid pain medication use. This patients provider noted that the patient has been treated with soma and oxycodone. The patients current treatment plan includes long-term use of oxycodone. However, the records provided for review do not support the long-term use of oxycodone. Further, the records do not document a trial and failure, or contraindication to treatment with the Health Plans formulary alternatives. With regard to biochemical equivalence, pooled head-to-head comparisons of opioids provide no rationale for preferring one opioid and/or administration route over another in the therapy of patients with chronic non cancer pain. For these reasons, the requested oxycodone 30 mg is not medically necessary for the treatment of this patients chronic low back pain.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 anesthesiology with subspecialty certification in pain management 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 enrollee is requesting authorization and coverage for Hyaluronan Injections (Synvisc) in both knees. The enrollee has bilateral knee osteoarthritis. Previous cortisone injections provided one week of benefit. An x-ray showed mild medial and patellofemoral compartment joint space narrowing and spurring. Her provider recommended hyaluronic acid injections (Synvisc) injections to her bilateral knees due to the enrollees mild degree of osteoarthritis and her decreased benefit from the cortisone injections. The enrollee notes she has finally found a treatment that worked and it has changed her quality of life. She is now able to squat with less pain to her knees, and going up and down the stairs is tolerable after the hyaluronic acid (Synvisc) injections. This enrollee is too young for total knee replacement surgery. The enrollee has tried and failed steroid injection therapy. This enrollees condition, two-compartment osteoarthritis, is an indication for management with hyaluronic acid (Synvisc) injections. The enrollee has experienced positive results with previous hyaluronic acid injections. Literature describes osteoarthritis as a common condition that results in pain, reduced mobility, and decreased function. Recent studies have shown hyaluronic acid injections (Synvisc) can provide longer-term improvement in both pain and function. Literature notes a single injection of hyaluronic acid (Synvisc) is safe and effective for six months in individuals with knee osteoarthritis. Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old male enrollee requested acupuncture for treatment of his tinnitus.   Findings:  The physician reviewer found that currently, there are no known effective medications to treat tinnitus (Baguley, et al). A thorough search of recent peer-reviewed medical literature reveals that acupuncture can improve tinnitus in some well-selected patients (Rogha, et al). Consequently, an acupuncture trial for this patients diagnosis of tinnitus is supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Clocortolone pivalate cream 0.1%. Both lichen simplex chronicus and lichen sclerosus of the genital skin are chronic diseases that are difficult to control. The use of topical class 1 corticosteroids is considered the mainstay of therapy for these conditions. The current medical literature and guidelines support the safety and efficacy of clobetasol for the treatment of lichen sclerosus. Researchers noted that for male patients, clobetasol propionate 0.05% ointment must be used once daily for one to three months with an emollient soap substitute and barrier preparation. There is a lack of randomized controlled clinical trials for male lichen sclerosus management. However, a large retrospective series demonstrated that 50% of male patients with lichen sclerosus responded to clobetasol propionate. This patients records do not document an adequate trial of treatment with clobetasol. For these reasons, the requested Clocortolone pivalate cream 0.1% is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee has requested for rehabilitation services for treatment of her condition. Findings:  The physician reviewer found that SNF-level rehabilitation services were no longer medically necessary as the patient was not and is not making further functional progress with continued therapy. She remains at the minimum and moderate assistance levels with lower extremity activities of daily living.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the EpiFix placental allograft skin substitute for treatment of the enrollees chronic right heel wound. Findings:  2/3 of the physician reviewers found that EpiFix is an amniotic membrane biologic product that has strong evidence for healing diabetic foot ulcers versus standard care. EpiFix is also superior to other biologics. Standard wound care includes debridement, glycemic control, offloading and infection control. Although the patient underwent debridement, the patient remained on Santyl for two years with little variation. Recent notes do not mention appropriate offloading such as a total contact cast. In this case, dressings including iodine based products, collagen, foam, were not exhausted. There was no mention of local tissue oxygenation. All told, the EpiFix placental allograft skin substitute was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: 2/3 of the 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in infectious disease 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.Physician reviewer number two 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 a similar medical condition.Physician reviewer number three 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.