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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Mavyret 100-40 mg. Findings: The physician reviewer found that according to the 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 recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage.  The ENDURANCE-1 trial showed that only eight weeks of treatment is needed. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 mg 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 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a consultation and surgery with a weight loss surgeon for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the requested services. Based upon the records provided, the patient does not present with morbid obesity (BMI of 40 or greater) or clinically severe obesity (BMI of at least 35 with serious co-morbid conditions). The patient underwent gastric bypass in the past, however there is no documented complication of the original procedure that requires surgical intervention. Moreover, there is no documentation of compliance with any form of post-operative dietary and behavioral follow-up. All told, the requested services are not medically necessary for treatment of the patients medical condition. 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 surgery and has completed a fellowship in minimally invasive/bariatric surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Aubagio tablets. The American Academy of Neurology (AAN) practice guidelines for disease-modifying therapies (DMTs) for adults with multiple sclerosis states that a change in therapy injection fatigue or injection-related pain or discomfort may be a common reason for poor adherence. Clinicians should discuss a change to non-injectable or less frequently injectable DMTs in people with MS who report intolerable discomfort with the injections or in those who report injection fatigue on injectable DMTs. According to the AAN, there are reports of progressive multifocal leukoencephalopathy (PML) with the use of both Gilenya and Tecfidera. The U.S. Food and Drug Administration (FDA) has approved Aubagio for the treatment of relapsing-remitting MS at 14 mg dose once daily. A review of a study compared the efficacy and safety of oral agents for the treatment of relapsing-remitting MS. The authors reported that clinical trials of Aubagio showed efficient annualized relapse rate and disability progression outcomes comparable to first-line drugs. This patient has relapsing remitting MS with symptoms of injection fatigue and side effects related to weekly injections with Avonex. Per the AAN practice guidelines, it is appropriate to switch to a non-injectable DMT. Two of the formulary alternatives, Copaxone and Extavia, are injectable DMTs and would not be appropriate for this patient. Gilenya and Tecfidera are oral DMTs but are not recommended given the patients JC virus seropositive status and risk for PML. Given these findings, the requested Aubagio tablets are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurology 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 36-year-old female enrollee has requested for Orthovisc injections for treatment of her bilateral chondromalacia patella. Findings:  The physician reviewer found that this patient does not meet the criteria under the plan guidelines for visco-supplementation inasmuch as there has not been documented failure of Tylenol, there has not been documented failure of four full-dose anti-inflammatories, and there has not been documented failure of at least one intra-articular corticosteroid injection.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for Ativan (lorazepam). The U.S. Food and Drug Administration (FDA) has approved Ativan for short-term relief of anxiety symptoms and for the treatment of epileptic seizures. The FDA has not approved Ativan or benzodiazepines for the treatment of chronic low back pain, or pain related to a hernia. A review by Tanguay Bernard and colleagues reports that patients with a history of substance abuse should not take benzodiazepines. In addition, providers should exercise caution with a patient that has other risk factors, including a history of chronic pain, polysubstance abuse, and untreated schizophrenia. In general, the use of both opioids and benzodiazepines is contraindicated due to concerns of respiratory depression, which is further elevated for this patient given his comorbid medical issues. Based on the medical records for review, lorazepam (Ativan) with refills 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 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested radiofrequency ablation for treatment of his venous insufficiency.    The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The medical records do not document compression stocking use.  A three-month course of conservative treatment is widely recognized by physicians treating this type of venous disease as appropriate prior to ablation.  The records do not document urgent issues such as bleeding or ulcer.  The Health Plans requirement that the patient complete a three-month course of conservative measures, including graded compression stockings, is medically appropriate.  All told, radiofrequency ablation was not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that 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 vascular surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients representative has requested reimbursement for air and ground ambulance transportation services. The records document that this patient had severe, end-stage cardiomyopathy secondary to ischemic heart disease. He was not considered a candidate for conventional open valve surgery and initially was considered for percutaneous mitral valve clip in Pennsylvania. He remained symptomatic and his providers recommended cardiac transplant evaluation. The advanced heart failure team in recommended transfer to California, due to the lack of social supports, which would prevent him from being placed on a donor list in Pennsylvania. As the closest transplant center to his home was Cedars Sinai in California, he required transport for further treatment and evaluation. He had Class IV congestive heart failure, dependent on milrinone inotropic support, oxygen and intravenous diuretics. Moreover, the patient had difficulty lying flat. Given the severity of his clinical cardiac condition, travel without medical support by commercial aircraft or ground ambulance would have been be clinically unsafe. Thus, air ambulance was the safest transport option for this patient. Left ventricle assist device (LVAD) implantations are different procedures than other cardiac procedures such as stent, a valve clip or even bypass surgery, which require short-term care. Implantation of an LVAD as a bridge to transplant requires the patient to remain close to the implanting center for close ongoing follow-up. Further, strong social support was needed given the importance of follow-up, psychological concerns, compliance with longer-term treatments. Based on these findings, the air and ground ambulance transportation services were medically necessary for this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer board certified in internal medicine with subspecialty 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: Upheld

Nature of Statutory Criteria/Case Summary: A patient requested authorization and coverage for admittance to residential treatment program. The Health Plan has denied reimbursement as not medically necessary. Findings:  The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the appropriate level of care. For a CALOCUS composite score of 15, the recommended level of care is low-intensity outpatient therapy.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 subspecialty certification in child and adolescent psychiatry 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: An enrollee has requested authorization and coverage for Orthovisc injections for treatment of the enrollees osteoarthritis in both knees. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity for the requested services. Current evidence based medical guidelines and literature support repeated cycles of viscosupplementation treatment to delay time to total knee replacement in patients with knee osteoarthritis who have failed conservative treatment, and state there is no maximum amount of injections established by high quality scientific evidence. However, in this patients case, the patient did not have a significant improvement in symptoms for six months or more to support repeat injections. The submitted records documented less than two weeks of pain relief. She has been treated with at least two prior courses of viscosupplementation. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 71-year-old male enrollee has requested stereotactic body radiation therapy (SBRT) for treatment of his prostate cancer.  Findings:  Two physician reviewers found that many clinical studies supporting the efficacy and safety of SBRT in the treatment of prostate cancer have been published. At least one study has shown excellent five-year biochemical control rates with very low rates of serious toxicity and additional studies have demonstrated the safety of SBRT for prostate cancer at two- to three-year follow-up. Although more long-term results are needed, the American Society of Radiation Oncology (ASTRO) policy update indicates that the current data support SBRT as an acceptable alternative. However, SBRT has not been proven to be superior to IMRT for treatment of prostate cancer. Therefore, the requested SBRT 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

A 30-year-old female enrollee has requested residential treatment center services for treatment of her behavioral health condition. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity for the services at issue. Secondary to the patients abusive upbringing, this patient has the most primitive of intrapsychic defenses and has experienced profound ego fragmentation; she has serious mental illness and grave disability. In reviewing the clinical notes, the patient was symptomatic throughout the disputed timeframe. The services provided during this time were for active treatment. Symptomatically, the patient had regular urges to restrict, purge, excessively exercise and skip meals. The patient also suffered from a firmly entrenched negative body image.  Although her weight had improved since admission, such distorted and pathological thinking was consistent with an individual who had not consolidated the treatment gains necessary to maintain weight and eat healthily in an unsupervised setting. The patient also endured feelings of suicidality, anxiety, worthlessness and self-loathing. Additionally, her disconnection, depression and disassociation remained prominent. The unresolved traumatic exposures of the patients past were fueling a robust symptom complex that she could not process in a reasonable manner.  In sum, the confluence of a persistent pathologically enmeshed trauma history and eating disordered cognitive schema, cast upon the under-developed sense of self, primitive coping skills, formidable symptom complex, disturbed personality organization and poor support system would have more than likely generated distress and functional impairment to an extent that would have undermined treatment at a lower level of care. Accordingly, the residential treatment provided from the time frame specified was safe, appropriate, consistent with good medical care and medically necessary. Thus, the services at issue were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female enrollee has requested bilateral reduction mammoplasty for treatment of her bilateral breast hypertrophy.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services in this patients case.  Breast reduction surgery is effective in relieving symptoms related to large breasts such as back pain, neck pain and skin breakdown.  In this case, there is documentation of shoulder bra strap grooving and intertrigo.  The Schnur scale was developed to relate the amount of breast tissue removed to preoperative body mass surface area as a means of differentiating cosmetic from reconstructive medically necessary breast reduction surgery.  In this patients case, the proposed amount of tissue to be removed meets Schnur scale criteria as a reconstructive procedure.  All told, the requested bilateral reduction mammoplasty is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 57-year-old male with an acoustic neuroma, apparently post-neurosurgery, with significant residual neurological deficits. The patient requires mechanical devices in order to function.  The patient experiences frequent falls. He was seen and treated by a neuro-otologist in 2003 and 2004. In addition, it appears the patient has left-sided deafness, impaired vision, and substantial loss of coordination. He has obtained a POV and lift and has requested reimbursement for the equipment at issue.  In many cases patients with an acoustic neuroma experience severe neurological deficits and require major rehabilitation and mechanical aides. Based upon the records provided, the patient is severely handicapped and cannot functionally ambulate or safely and effectively operate a manual wheelchair. He requires mechanical aides that are necessary for his ability to function. Though rehabilitative services may eventually help him become less dependent on mechanical devices, the evidence provided demonstrates the equipment at issue is medically necessary at this time. Therefore, I have determined that the equipment at issue is medically necessary for the patients mobility. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for a customized oral device/appliance. The submitted documentation does not support that the requested device is medically necessary. An oral appliance is used in patients with significant obstructive sleep apnea who are unable to tolerate positive airway pressure therapy. In this case, the patient had a home sleep study. Home sleep studies are generally not very accurate. With no significant daytime sleepiness and a very mild sleep apnea, oral appliance therapy is not indicated. Accordingly, a customized oral device/appliance is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested device 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 otolaryngology 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: An enrollee has requested authorization and coverage for 70 tablets of Percocet 5-325 mg.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication regimen. Clinical practice guidelines do not support the use of opiates for chronic low back pain. Further, the use of marijuana violates her opiate maintenance agreement. Per the medical evidence, the use of marijuana increases her risk of using other drugs and opiate misuse. Therefore, 70 tablets of Percocet 5-325 mg are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 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: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Claravis. The submitted documentation does not support the medical necessity of the requested medication. The patient has requested coverage for Claravis as treatment for recalcitrant nodulocystic acne. The medical evidence supports evaluation by a dermatologist in order to determine other appropriate treatment options. In this patients case, the medical records do not indicate that other systemic approaches to her acne were discussed. Specifically, spironolactone may be an appropriate choice for this patient. There is a lack of support for Claravis in this clinical setting. Therefore, Claravis is not medically necessary for this patient at this time.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.