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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Mavyret 100-40 mg tablet for eight (8) weeks. Findings:  The physician reviewer found that according to the most recent 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 support treatment with Mavyret for non-cirrhotic treatment naive genotype 1 patients for eight 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. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret 100-40 mg tablet for eight (8) weeks is supported as 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 27-year-old female enrollee requested authorization and coverage of chromosomal analysis.  The enrollee has had two previous fetal demises.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested testing is not medically necessary for treatment of the patients medical condition at this time.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for a recliner bath lift. Findings:  The physician reviewer found that based upon the descriptions provided, an automated assisted device is appropriate since her weight of 160 pounds is not easily manageable by a single caregiver. However, a recliner bath lift is inadequate to handle present and future transfer issues. The DME evaluation recommended a tub buddy system which allows the patient to more easily transition into the tub without relying exclusively on hip flexion strength or the caretaker to enter the tub. Based upon the reported assistance required for transfers and mobility, a recliner bath lift is inadequate. A shower tub buddy transfer system is more appropriate based upon the patients reported functional deficits. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with sub-specialty certifications in pain medicine and occupational 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for XomeDx (whole exome sequencing) Trio  GeneDx. Findings:  Two of the three physician reviewers found whole exome sequencing is a technology whereby the portion of the genome consisting of coding sequences is analyzed to look for variants that may explain the patients phenotype. Whole exome sequencing may be indicated when there is a suspected genetic disorder based on signs and symptoms, with no known single gene condition fitting the phenotype. Initial studies show a diagnosis is made by exome sequencing in approximately 25% of patients referred for testing. The vast majority of these patients had a neurological phenotype, a category into which the patient may fit given her history of migraines and stroke-like episodes. In this case, the results from the requested services are likely to impact patient management. In sum, XomeDx (whole exome sequencing) Trio  GeneDx is likely to be of greater benefit than other methods of evaluating this patient.Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1 is board certified in clinical biochemical genetics and is actively practicing. Physician reviewers 2 is board certified in clinical genetics and genomics and is actively practicing. Physician reviewers 3 is board certified in cytogenetics and genomics and is 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: Overturned

A 34-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old female enrollee has requested Lyrica 75 mg daily for treatment of her neuropathic pain.  Findings:  The physician reviewer found that based on the records provided for review, the requested Lyrica 75mg per day is medically necessary treatment for the patients medical condition. The patient has already failed to benefit from standard therapy including generic gabapentin. Her medical condition qualifies as chronic and seriously debilitating. Additionally, Lyrica is supported in the peer-reviewed medical literature as a safe and effective treatment for several neuropathic conditions. The patients symptoms are characteristic of neuropathy and she has a documented positive response to Lyrica. Gilron reviewed the evidence based literature supporting the use of Lyrica for patients with chronic neuropathic and early post-surgical pain. The authors found that multiple, large, high quality trials have demonstrated the safety and efficacy of Lyrica in neuropathic pain. The review concluded that Lyrica is efficacious treatment for neuropathic and post-surgical pain. Therefore, the medical literature supports the safety and efficacy of Lyrica 75mg per day for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting reimbursement for Euflexxa injections for both knees. The enrollee has bilateral knee primary osteoarthritis. Physical exam notes describe bilateral bony changes to the knees, but no warmth or effusions. A progress note shows normal knee alignment, with the joint line/retropatellar area noted as tender to palpation. Records indicate the enrollee has utilized ice packs and medications including gabapentin, 600 milligrams twice a day; and Percocet on an as-needed basis, for pain control. This enrollee has received hyaluronic acid injections with good interval relief. She has developed recurrent pain and would like to repeat the injections bilaterally. The enrollee continues to receive the injections regularly because they are effective for her pain. The enrollee has bilateral knee pain secondary to osteoarthritis (OA). Management with hyaluronic acid injections has yielded positive results. Literature notes clinical studies indicate hyaluronic acid injections are effective for treatment of local osteoarthritis, with a high rate of responders among those with osteoarthritis of the knee. Hyaluronic acid injections improve pain and function, while avoiding the use of anti-inflammatory treatment and corticosteroids. Individuals usually tolerate the injection well and, with careful administration, the rate of complications is low. Researchers commented on previous systematic reviews of hyaluronic acid injections, noting the clinical benefit of hyaluronic acid injections is underestimated using conventional analysis methods. When accounting for control group effects in hyaluronic acid injection studies, it can be reasonably concluded that hyaluronic acid injections may be beneficial for a large number of those with knee osteoarthritis.  This enrollee has used over-the-counter medications and assistive devices. Hyaluronic acid injections provided a positive result in terms of decreased pain, decreased use of oral medications and increased function.Final Result: The reviewer determined that the requested services were 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injection series in the left knee. Findings: Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of severe glaucoma and corticosteroid injections are contraindicated. Overall, the patients treatment options are limited. The requested viscosupplementation with Orthovisc injections of the left knee is appropriate for treatment of this patients osteoarthritis of the left knee. Therefore, the requested Orthovisc injection series in the left knee is medically necessary for 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 sixty-four year-old male with multiple chronic problems and deconditioning is requesting authorization of acute inpatient rehabilitation services.  Reviewers Findings:  The reviewing physician found that there is no evidence in the literature that acute rehabilitation is superior to a less intense rehabilitation program for general reconditioning of chronically ill individuals.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for re-admission to an outpatient neurological rehabilitation day program (3 hours/day; 5 days/week). Researchers describe progressive multifocal leukoencephalopathy (PML) as a rare opportunistic infection that occurs in patients whose immune system is compromised either because of an underlying illness or an immunosuppressive medication. The authors note that John Cunningham (JV) virus, prevalent in 60% or more of the adult population as a latent or persistent infection, is responsible for the syndrome of PML. Clinical symptoms may involve multiple domains, including cognition, vision, speech, behavior, sensation, motor function and gait. Motor dysfunction related to PML often manifests as hemiparesis. Treatment in cases of an allogeneic organ transplantation may include an adjustment of the immune suppressive therapy, and otherwise includes symptomatic and supportive care, including the treatment of complications such as seizures and psychiatric symptoms. In this case, the patient underwent a liver transplantation, which was complicated postoperatively by PML. The provider noted improvements following adjustments in the patients immunosuppressive regimen. Despite extensive rehabilitation, the patients gains have been modest overall and the patient continues to require extensive assistance for basic and instrumental ADLs due to multiple, severe, and persistent deficits related to his underlying, multifocal, degenerative brain disease. While records reflect that the patient recently sustained a left hip fracture which was surgically repaired, there is no indications that he requires or would be expected to marginally benefit from intensive outpatient multidisciplinary rehabilitation over usual rehabilitative services for hip fracture convalescence, if needed. Given that the patients primary deficits are due to a severe, progressive infectious condition, and that his clinical outcomes are not expected to be a function of the intensity of the rehabilitation services he receives, the requested services are not medically indicated. Therefore, re-admission to an outpatient neurological rehabilitation day program (3 hours/day; 5 days/week) is not medically necessary for the treatment of this patient.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 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: Experimental/Investigational
Decision: Upheld

A 21-year-old female enrollee requested insulin potentiation therapy and low dose chemotherapy for medical treatment of her ovarian cancer.  Findings:  Three physician reviewers found that the services at issue were not and are not likely to be more effective for this patient than other available treatment options. Insulin potentiation therapy and low dose chemotherapy has not been supported by the scientific community, and there is a lack of published clinical trials of sufficient quality and scope to support its use in clinical practice. Therefore, the services at issue were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Urgent Care
Decision: Upheld

A 23-year-old male enrollee has requested an emergency room visit for the treatment of his fever and sore throat. Findings:  The physician reviewer found that the patient is a 23-year-old male who presented to the emergency department complaining of sore throat, fever and abdominal pain that had spontaneously resolved. He had no significant past medical history. It does not appear as though he made any effort to contact his primary care doctor or visit an urgent care center. His exam was benign, other than for pharyngeal erythema and bilateral exudates. He was diagnosed with acute pharyngitis, prescribed antibiotics and discharged for outpatient follow-up. This patient could have contacted his primary care physician or an urgent care facility instead of going to the emergency department. His condition clearly was not life-threatening, and the typical layperson would realize this.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A transgender female enrollee has requested authorization and coverage for laser hair removal. Findings:  The physician reviewer found that the requested services are medically necessary for treatment of the patients medical condition in this clinical setting. Facial hair removal is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. Excessive facial hair in a female would be considered abnormal and is referred to as hirsutism. Hirsutism is a medical diagnosis where terminal hair grows in female in areas that are normally found in males. This would include the face and parts of the genitalia. A female would be expected to have terminal hair in the scalp, axilla and on the arms and legs. This patients excessive facial hair is more consistent with the male gender. Additionally, hormone therapy has not been effective in improving this patients medical condition. Therefore, facial hair removal is medically necessary for the treatment of this patients gender dysphoria.With regard to whether the requested services are considered reconstructive in nature, excessive facial hair in a female is an abnormal body structure.  Hirsutism is a condition that is congenital in that the hair growth is determined by the genetic and hormonal makeup of the patient. As such, the requested facial hair removal can provide a minimal improvement in the appearance of terminal hair and create as normal an appearance as possible in this patient. Moreover, the requested services are going to improve emotional function for this patient. All told, laser hair removal is reconstructive in nature.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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for water circulating cold pad with pump for treatment of the enrollee, who is status post anterior cruciate ligament reconstruction. Findings:  The physician reviewers found that the records support a portion of the device at issue.  In this case, the patient underwent anterior cruciate ligament reconstruction.  There exists significant evidence that the use of a motorized cooling pump after knee surgery improves pain outcomes in the early postoperative period.  However, this case involved a purchase of the device at issue.  The scientific literature supports a seven-day rental of the water circulating cold pad with pump.  In sum, a seven-day rental of the device at issue was likely to have been more efficacious than other treatment options. Final Result: Two of three reviewers determined that a portion of the device at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications:  Physician reviewers number one, two, and three are board certified in orthopedic surgery and 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral custom foot orthotics. The submitted documentation supports the medical necessity of the requested equipment. The records document foot pain, metatarsalgia, a painful tailors bunion, and flat feet/pes planovalgus. The patients provider has recommended a pair of custom foot orthotics. Custom foot orthotics are utilized to support certain areas of the foot during gait, and reduce the range of motion of painful joints. In this patients case, custom orthotics would support this patients flat feet, alleviate strain of the longitudinal arch, and reduce pain to the forefoot, including below her metatarsal heads as well as the painful tailors bunion. Therefore, the requested bilateral custom foot orthotics are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is 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 podiatry 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 male enrollee has requested coverage for transoral incisionless fundoplication for treatment of his gastroesophageal reflux disease.  Findings:  Two physician reviewers found that although laparoscopic Nissen fundoplication is the standard surgical treatment for gastroesophageal reflux disease, surgical complications and postoperative pain have prompted multiple alternative interventions, including transoral incisionless fundoplication.  Contemporary literature suggests that this procedure can complement the current surgically and medically available options for treatment of gastroesophageal reflux disease.  Transoral incisionless fundoplication appears to hold promise for selected patients with symptomatic gastroesophageal reflux disease.  However, complications, including hemorrhage, emphasize the potential risk of the procedure.  The risk of complication with transoral incisionless fundoplication must be balanced with the variable therapeutic gain of the procedure.  Narsule and colleagues reported that 8.6% of patients had no improvement in gastroesophageal reflux disease after transoral incisionless fundoplication.  At this time, further studies with more patients and a longer follow-up course are needed to better assess efficacy. Long-term follow-up and randomized trials are needed to assess safety and durability of response compared with conventional surgical repair.  All told, transoral incisionless fundoplication is not likely to be of greater benefit than other available treatment options.