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

A 34-year-old male enrollee requested authorization and coverage of remicade therapy  for the treatment of sarcoidosis.  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 remicade therapy is likely to be more beneficial for treatment of the enrollees sarcoidosis 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

A 39-year-old female enrollee has requested Botox for treatment of her migraines. Findings:  Three physician reviewers found that this patients history is consistent with chronic migraine. She has been treated with three classes of standard migraine therapies without significant relief of symptoms or has experienced intolerable side effects. Her provider has recommended treatment with Botox, which has been shown in at least two large placebo-controlled, double blind, randomized studies to be effective in the management of migraines. At this time, Botox is becoming widely used by specialists for patients who fail treatment with multiple standard therapies and is likely to be more beneficial for treatment of this patients chronic migraine than standard alternatives.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication Zepatier. The enrollee has a history of Hepatitis C. She was treated with Interferon-based therapy. She achieved a high viral response from this treatment, but her viral loads are now high.  A sonogram of the liver showed normal hepatic elasticity. Laboratory results showed moderately elevated liver enzymes. She has a metavir score of FO-1. This places her in the absent-to-mild fibrosis, low-risk category for significant fibrosis/stenosis. The recent progress note documents her gastroenterologist recommended Zepatier because she has had Interferon treatment in the past. The health plan has denied authorization, indicating Zepatier is covered for the treatment of chronic Hepatitis C, genotype 1 for patients that have compensated liver disease by fibroscan ultrasound or biopsy documenting stage 2,3, or 4 fibrosis, NS5A resistance testing is required.  For the treatment of Hepatitis C, the preferred agents are Epclusa, Harvoni, and Vosevi. The enrollee has a history of hepatitis C and was previously treated with interferon.  The genotype is reported to be 1a.  She does not have cirrhosis. Professional societies  recommended Zepatier as a treatment for HCV genotype 1a, interferon-experienced persons; but only if they do not have resistance variants.  To utilize this medication regimen, resistance testing needs to be performed.  There was insufficient evidence in the record that resistance testing was performed. Epclusa, an alternative medication, is also a recommended regimen for HCV genotype 1a interferon-experienced patients and does not require resistance testing.   Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the substance abuse residential treatment center (RTC) services for treatment of the enrollees substance abuse and depression. Findings:  The physician reviewer found that The patient was not in withdrawals on admission, and was not placed on any type of withdrawal protocol. She was not a danger to herself or others, nor was she aggressive or violent. She showed no self-harming behaviors. She was cognitively intact and was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care. She was not psychotic, delusional, or manic. There was no evidence of a high degree of impulsivity, agitation, depression, or any other significant symptom that would interfere with her care. She was medically and psychiatrically stable. Her medication regimen was not complex and could have been started and monitored in an ambulatory setting. She participated in her care and required further treatment to help develop coping skills and relapse prevention. However, this also could have been carried out on an ambulatory basis. The patient did not require the structured environment of residential treatment center (RTC) level of care. All told, the substance abuse RTC services were not medically necessary for treatment of this patients behavioral health issues 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 sub-specialty certification in addiction 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a 3 Tesla magnetic resonance imaging (3T MRI) of the prostate. Active surveillance, a management strategy involving serial PSA testing and biopsies, allows safe monitoring of disease progression while reducing rates of overtreatment in patients with prostate cancer. The American Urological Association (AUA) guidelines state that, clinicians may consider multiparametric prostate MRI as a component of active surveillance for localized prostate cancer patients. In the medical literature, 3T multiparametric MRI has been shown to have a role to aid in active surveillance protocols and guide clinical decision-making. In the medical literature, 3T MRI is associated with improved detection rates and the study will permit re-biopsy of the abnormal lesion using the electronic tracking method. Importantly, 3T MRI is helpful in selecting appropriate patients for active surveillance. In this patient, 3T MRI is critical for adequate monitoring along with PSA and digital rectal examination based on the medical records provided for review and current AUA guidelines. Therefore, the requested 3T MRI is medically necessary for evaluation of this patient.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for MRI of the spine (CPT 72157, 72156, and 72158). The enrollee is status-post wide excision of a left medial thigh myxoid liposarcoma. Margins of resection were negative. His post-operative course was complicated by development of a seroma, which improved on interventional radiology drain placement and antibiotics, but re-accumulated once his drain was removed. The enrollee completed radiation therapy. His recent computed tomography (CT) of the chest, abdomen and pelvis was negative for metastatic disease. His physician ordered a magnetic resonance imaging (MRI) scan of the femur and spine. His provider noted an MRI is necessary when screening for spinal metastasis because there have been multiple case reports of spinal metastases being discovered on MRI that were not noted on other imaging modalities. The medical record demonstrates the enrollee has a unique and unusual condition. He had undergone resection of a myxoid liposarcoma complicated by seroma. He is also morbidly obese; with a weight greater than 400 pounds.  He continues to have problems with fluid accumulation at the surgical site.  His physician most recently aspirated 500cc.  This is significant for chronic inflammation of unknown etiology. Subsequent imaging was negative for metastatic disease.  These findings were suggestive of no evidence of metastatic disease to the chest and abdomen; however, they do not rule out spread to the primary site and bone. Literature describes studies that reported spread of the disease to the bone and spine.  Studies show how an MRI can provide tumor identification in the spine status-post surgery to an extremity. These studies support imaging of the entire spine to rule out metastatic foci.  Although the enrollee has received radiation to the primary site, it is unknown whether skeletal metastasis has occurred.  The only way to determine metastasis would be with an MRI.  Literature  notes it would be the most sensitive; studies concur with this conclusion. An MRI to the entire spine would allow for grading for prognosis and management.Final Result: The reviewer determined that the requested service is 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 28-year-old female enrollee has requested continuation of inpatient level of care for treatment of her L1 compression fracture status post fall off a horse.  Findings:  The physician reviewer found that consistent with the medical literature, significant ligamentous spinal injuries are an absolute indication for surgical repair as there is a high chance for gibbous deformity, instability, and nonunion in the ligamentous injury group (Vaccaro, et al). Although most fractures at the thoracolumbar level do not require surgery, the exception is the fracture associated with significant ligamentous disruption. The surgeons operative note in this patients case documented significant ligamentous disruption therefore the surgery was clinically indicated. The providers notes of the date in question indicate that the patient continued to require significant assistance for mobility. By the next day, the patient was appropriately prepared and discharged to home. Given the severity of the patients injury and surgical repair, the continued inpatient level of care was medically necessary during the said timeframe.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old male enrollee has requested for subacute residential level of care for treatment of her substance abuse and major depression. Findings:  The physician reviewer found that the diagnoses of Major Depression and Oppositional Defiant Disorder are not clearly established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Humira, inject 160 mg (two pens) subcutaneously on day one, then inject 80 mg (one pen) subcutaneously on day 15, then start maintenance inject 40 mg (one pen) every other week. The records provided for review document that this patients symptoms and colonoscopy findings are consistent with moderate-to-severe Crohns disease. The American College of Gastroenterology (ACG) supports treatment with anti-tumor necrosis factor (TNF) medications such as Humira for the treatment of Crohns disease (Talley, et al.; Lichtenstein, et al.). Alternatives such as mesalamine are no longer recommended for primary therapy of Crohns disease, and corticosteroids are not appropriate for long-term primary therapy of Crohns disease. Immunosuppressants are unlikely to be effective for approximately 17 weeks, and are not recommended as monotherapy for induction of disease control in moderate to severe disease (Terdiman, et al.). Corticosteroids, mesalamine, methotrexate, and antibiotics are not appropriate long-term primary therapy for moderate-to-severe Crohns disease. Lack of treatment may result in worsening loss of disease control and complications. The dosing regimen requested is the U.S. Food and Drug Administration (FDA) approved dosing regimen for initiation of Humira. For these reasons, Humira at the dosing requested Humira injection 160 mg (two pens) subcutaneously on day one, then 80 mg (one pen) subcutaneously on day 15, then maintenance Humira 40 mg injection (one pen) every other week) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 subspecialty 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

A 58-year-old female enrollee has requested for Avastin therapy for treatment of her colon cancer.   Findings:  Two physician reviewers found that there is a lack of evidence in peer-reviewed, medical literature that supports the efficacy of single-agent maintenance Avastin for colorectal cancer. There were two studies cited on behalf of the patient. In the E3200 study, the overall survival as noted by the authors was probably due to post-progression chemotherapy. The progression-free survival of the Avastin-alone group was significantly lower than the chemotherapy group, and a decision was made to not study this group any further. Additionally, in response to the study noting two patients who crossed over to single-agent Avastin, a determination cannot be made as to the safety and risk/benefit ratio based on the responses noted in these two patients in a small study. The expert consensus panel recommendations from the NCCN do not support the use of single-agent Avastin, and Avastin is FDA approved specifically in combination with a 5-FU analog-based treatment.
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old male enrollee has requested reimbursement and prospective authorization and coverage for Bicillin LA for treatment of the enrollee, who has a stated condition of Lyme disease.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the medication at issue in this patients case.  Per serological testing , there is no evidence of Babesia, Bartonella, Ehrlichia, or Borrelia infection.  The medical records do not support a diagnosis of viral encephalitis.  There is no record of a tick bite, and there is no documentation regarding the characteristic rash of early Lyme disease.  Per the submitted documentation, there is no clinical or serological evidence of infection in this patients case.  This patients medical records do not demonstrate the medical necessity of antibiotics in this patients case.  Of note, Bicillin LA has not been proven to be an effective treatment for patients with Lyme disease.  All told, Bicillin LA was not and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 30 chiropractic treatment visits. After careful review of the current evidence-based practice guidelines, the request for 30 chiropractic treatments visits for maintenance care is not supported by the medical records provided for review. In this patients clinical setting, the International Chiropractic Association (ICA) recommends 12 chiropractic visits, over six to eight weeks, to achieve improvement. The records provided for review document that this patient has been treated with medications, physical therapy, chiropractic care, and home exercise. The provider noted the patient experienced relief of symptoms with previous chiropractic treatment in four to eight visits. Given these findings, 12 chiropractic visits are medically necessary for management of this patients chronic neck and upper back pain.Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is a board certified chiropractor 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 38-year-old female enrollee has requested anesthesia for treatment of her history of gastroesophageal reflux disease and Schatzkis ring status post dilatation.  Findings:  The physician reviewer found that monitored anesthesia care is directly administered by anesthesia personnel. Monitored anesthesia care may include varying levels of sedation, analgesics, and anxiolysis. Per the standards of the American Association of Anesthesiologists, monitored anesthesia care should be provided by qualified anesthesia personnel who must be present continuously to monitor the patient and provide anesthesia care. The American College of Gastroenterology states that the use of deep sedation is medically necessary when there is documentation by the endoscopist and the anesthesiologist that specific risk factors or significant medical conditions are present. Those risk factors or significant medical conditions include prolonged or therapeutic endoscopic procedures requiring deep sedation, increased risk for complications due to severe comorbidity and history of anticipated intolerance to standard sedatives.  Additionally, patients younger than 12 years of age, patients age 70 or older, patients who are pregnant, acutely agitated uncooperative patients and patients at increased risk for airway obstruction due to anatomic variation may require monitored anesthesia care.  The medical documentation indicates that the patient had no specific medical comorbidity that necessitated the use of monitored anesthesia care for the upper endoscopy performed on the said date. The patient was an acceptable and appropriate candidate for moderate sedation to be administered by the endoscopist. All told, anesthesia provided on the date in question was not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for HP Acthar Gel 80 units. The submitted documentation supports the medical necessity of the requested medication. The U.S. Food and Drug Administration approved the use of Acthar Gel for exacerbations of multiple sclerosis. Standard therapy for acute exacerbations of multiple sclerosis include high-dose corticosteroid therapy, plasmapheresis, and intravenous immunoglobulin (IVIG). Researchers note that Acthar Gel may be considered as an alternative treatment option and that its efficacy and treatment outcomes may be comparable to those seen with corticosteroids. Reasons for treatment with Acthar Gel may include a lack of benefit established with corticosteroids, inability to tolerate corticosteroids or adverse effects, and poor access to intravenous treatment. In this case, the patient has multiple sclerosis with exacerbations despite disease modifying therapy with Ocrevus. She has experienced relief without side effects using Acthar Gel in the past. Based on current medical literature showing Acthar Gels efficacy and the patients past successful outcomes, Acthar Gel is medically indicated for this patient. Therefore, HP Acthar Gel 80 units 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.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested for Procrit injections for treatment of her chronic myelogenous leukemia. Findings:  The physician reviewer found that Procrit is indicated for anemia associated with the use of chemotherapy for the treatment of non-myeloid malignancies. Thus, it is not indicated for use in patients with chronic myelogenous leukemia. In addition, Procrit is generally used to maintain a hemoglobin between 10 and 12 g/dl.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 27-year-old woman who sustained a severe fracture to her elbow, which required surgical intervention. She was taken to surgery on 4/4/05 and discharged on 4/6/05. The submitted chart notes reveal that postoperatively the patient was in severe pain (as would be expected) and required a PCA. She was to be discharged on 4/5/05, but was noted to have pain and swelling. Therefore, the patient remained hospitalized until 4/6/05. The Health Plan indicates inpatient services were not medically necessary beyond 4/5/05.Given the type of significant injury sustained by the patient and the complicated surgery that was performed, it is not unreasonable or inappropriate for a patient to stay an extra day for pain control and observation. Significant swelling could lead to compartment syndrome or other serious complications. In the case of this patient, her provider had concerns regarding her pain and condition. The additional night stay was medically reasonable and appropriate. Therefore, I have determined the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.