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

Nature of Statutory Criteria/ Case Summary:  The enrollees representative is requesting reimbursement for and future authorization and coverage for the medication, Xifaxan. Findings:  The physician reviewer found that the enrollee is diagnosed with small intestinal bacterial overgrowth (SIBO) and irritable bowel syndrome (IBS) with diarrhea.  Her symptoms include bloating, aching, and eructation.  She has been taking omeprazole, but symptoms persist. An (EGD) esophagogastroduodenoscopy demonstrated gastric erosion.  Her gastroenterologist recommended 550mg Xifaxan (rifaximin) three times per day for 14 days. The medical literature notes that Xifaxan is indicated for treatment of irritable bowel syndrome with diarrhea (IBS-D) in adults. It is also recommended for patients with hydrogen predominant bacterial overgrowth. Antibiotic therapy is typically begun on an empiric basis and studies suggest that clinical response rates may be higher with rifaximin (Xifaxan) than with other antibiotics. Shayto and colleagues indicate that rifaximin has been shown to improve symptoms in small intestinal bacterial overgrowth. The FDA has approved Rifaximin for IBS with diarrhea. The medical literature supports the use of rifaximin for small intestinal bacterial overgrowth. The alternative antibiotics that have been offered are not as effective for small intestinal overgrowth. Final Result: The reviewer determined that the requested medication is 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: An enrollee has requested Sovaldi with Ribapak for treatment of the enrollees chronic hepatitis C virus genotype 2. Findings: The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. Per the guidelines, in treatment-naive genotype 2 patients, therapy is recommended with Sovaldi/Daklinza or Epclusa. This recommendation is based on the two studies for Sovaldi/Daklinza, and the ASTRAL-2 trial for Epclusa (Wyles, et al; Sulkowski, et al; Foster, et al). Sovaldi and ribavirin (or Ribapak) are no longer recommended. For these reasons, although hepatitis C treatment is indicated, the request for Sovaldi and Ribapak for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medications 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 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

The parent of a 13-year old male has requested bilateral mastectomy for the treatment of the enrollees gynecomastia. Findings:  The physician reviewer found that the submitted evidence does not demonstrate the procedure at issue was reconstructive in nature as defined by Californias reconstructive surgery statute. The patients condition is a natural consequence of obesity in adolescent males and did not constitute an abnormal structure of the body.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Repatha SureClick Auto-Injector. Findings: The clinical indication for PCSK9 inhibitors such as Repatha includes patients with clinical atherosclerotic cardiovascular disease and those with familial hypercholesterolemia who are on maximally tolerated statin therapy and require greater reduction in LDL cholesterol levels to reach their goal. The indication has also been extended to such patients with statin intolerance, generally due to myalgias and/or myopathy secondary to statin drugs with significant LDL cholesterol elevations. This patients records do not include any documentation of vascular disease or diabetes. The provider noted that the patient experienced possible joint pain and myalgias with rosuvastatin. However, the records do not indicate that treatment with another statin was attempted. Additionally, without a statin, the patients LDL cholesterol was 95 mg/dL on ezetimibe alone, which is within the published guidelines for a patient with a family history of coronary artery disease as the primary risk factor. Given these findings, the requested Repatha SureClick Auto-Injector 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 internal medicine with subspecialty certification in cardiology 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 parent of an enrollee has requested additional hours per week (for a total of 30 hours) of applied behavioral analysis (ABA) services for treatment of the enrollees medical condition. Findings:  Two physician reviewers found that in this clinical setting, an increase of ABA services to 26.5 hours per week is medically necessary. The research study done by Orinstein and colleagues found that children with optimal outcome after an autism diagnosis were more like to receive ABA and more likely to start it at an earlier age. However, the children with optimal outcome had a mean of 25 hours or services in age 4 and 18 hours at age 3. According to the documentation submitted for review, the patient is having worsening of maladaptive behaviors, thus his current ABA frequency is not sufficient. However, the patient shows cognitive, communication and adaptive progress with the current level of hours.  Final Result: Two reviewers determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: One reviewer is board certified in child neurology and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. One reviewer is board certified in pediatrics and child neurology and is 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: Experimental/Investigational
Decision: Upheld

A 35-year-old male enrollee requested authorization and coverage of radiofrequency ablation. The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees varicose veins. Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old male has requested bariatric surgery for treatment of morbid obesity.  Findings:  The physician reviewer found that the patient meets the National Institutes of Health (NIH) guidelines for weight loss surgery. There is no scientific evidence that any pre-operative weight loss predicts the long-term outcome of weight loss surgical procedures. Nor is there scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Stelara 90 mg every six weeks. This patient has symptoms consistent with active Crohns disease despite treatment with Stelara dosed at 90 mg every eight weeks. Her provider has recommended a dose increase to include 90 mg every six weeks. One large randomized controlled trial demonstrated the safety and efficacy for induction and maintenance of remission in patients with moderate-to-severe Crohns disease resistant to anti-tumor necrosis factor (TNF) therapy, which this patient has failed (Sandborn, et al.). Another study showed a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for one year (Kopylov, et al.). The mechanism of action in Stelara is different than that of anti-TNF medications, and the other medications which this patient has failed (Tuskey and Behm). Another study showed that a large proportion of patients were able to maintain response with Stelara dose escalation to 90 mg every four weeks (Kopylov, et al.). In this case, the patient has failed high-dose Remicade. She demonstrated disease symptoms on Stelara dosed at every eight weeks. The patients Stelara level on testing was unlikely to be sufficient to control her Crohns disease (Battat, et al.). Continued use of Stelara every eight weeks or a change to another medication may result in worsening disease control and potential complications. Given these findings, the requested Stelara 90 mg every six weeks is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication dosage 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Orencia Clickject subcutaneous auto-injector. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients rheumatoid arthritis. The submitted documentation supports the medical necessity of the requested medication. The U.S. Food and Drug Administration has approved Orencia for the treatment of patients with moderately to severely active seropositive RA, who have had an inadequate response to one or more disease modifying anti-rheumatic drugs or tumor necrosis factor inhibitor. In this case, the patient is noted to have infections with tumor necrosis factor inhibitors. The literature does demonstrate lower rates of infections with Orencia. Given the patients infection history, switching to another agent would be warranted. As such, Orencia Clickject subcutaneous auto-injector is medically necessary for 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 internal medicine with sub-specialty certification in rheumatology 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 OxyContin for the treatment of his medical condition.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the medication at issue.  This patient has chronic nonmalignant pain.  The current standard of care for chronic pain in this setting is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.  There are a variety of anticonvulsants and antidepressants considered adjunctive to this therapy.  If there is poor response to conservative therapy, then surgery should be considered.  High-dose opioids are associated with a high-risk of dependence and tolerance and are not recommended.  All told, OxyContin was not and is not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was not and 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

The parent of a 17-year-old female enrollee has requested partial hospitalization program services for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that this patient was referred to a PHP based on clinicians input that she needed more intensive services to address her chronic eating disorder. At the time of those referrals and as documented on admission, there were no identified medical issues (such as severe weight loss, persistent binging/purging, electrolyte abnormalities, evidence of protein depletion or cardiac symptoms) to indicate the need for immediate medical interventions. Furthermore, the patient did not manifest any suicidal or homicidal ideation, delusions or marked mood changes. To the contrary, the admission documentation indicates that her mood and eating disorder symptoms had improved with the addition of Zoloft approximately three months prior to admission. She was also documented as being motivated for treatment and she had solid future oriented ideation around a specific career. While the psychiatrist indicates the potential for minimization and denial of severity, the patient does demonstrate a willingness to accept structure and treatment recommendations as manifested by her volunteering activities during her days off. Thus, a less intensive level of care such as the IOP and outpatient therapy services offered by the Health Plan would be consistent with the standard of care and medically appropriate in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the advanced lipoprotein testing. This patient has a reported history of hyperlipidemia but no other risk factors for cardiovascular disease. She is being treated with atorvastatin 20 mg and is well below goal low density lipoprotein (LDL) cholesterol. In addition, she has a good high density lipoprotein (HDL). Moreover, the current guidelines do not suggest that advanced lipid profile monitoring, including LDL particle number or size, would provide substantially better cardiovascular risk prediction than standard risk profiling. Overall, the consensus remains that advanced lipid testing results should not alter a patients treatment in this clinical setting. For these reasons, the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in internal medicine with subspecialty certification in cardiovascular disease and are actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and interventional cardiology 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: Experimental/Investigational
Decision: Overturned

A 48-year-old female enrollee requested authorization and coverage of continued Botox injections. The Health Plan  denied the request indicating that the requested therapy is considered experimental for the treatment of the enrollees headaches.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old male enrollee has requested proton beam radiation therapy for the treatment of his pre-sacral chordoma. Findings:  The physician reviewer found that this patient appears to have a locally aggressive pre-sacral chordoma. The Health Plan offered a team of oncologic surgeons, including orthopedic, spine and general, to perform the second surgical procedure. The outcome of that surgery is not known. The patients needs in regard to post-operative radiation therapy are dependent upon the surgical  result. If the surgical excision was not complete and there is discernible residual tumor, the precision of proton beam radiation therapy is clinically indicated. However, if there is no discernable residual tumor, IMRT is appropriate for post-operative radiation therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old male enrollee requested joint manipulation under anesthesia for medical treatment of his contracture at the interphalangeal joint of the right thumb.  Findings:  Two physician reviewers found that according to the documentation provided, the patient initially underwent a nerve repair, following a table saw injury. The patient then attended several occupational therapy sessions following the nerve repair. Although it is noted that the patient developed an early contracture of the interphalangeal joint, there was no documentation of an attempt at conservative management in the form of splinting, casting, or injections. Further, there is a lack of peer-reviewed literature supporting the efficacy of manipulation under anesthesia for joints of the wrist and hand. Although the patients excessive vasovagal response is noted, there was no documentation of attempts at conservative management in the form of splinting, casting, or injections.  Based on the clinical information received and the current peer-reviewed medical literature, the joint manipulation under anesthesia was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The patient has been diagnosed with osteoarthritis on both knees. The provider noted the patient had good results with viscosupplementation injections in the past. The patient has tried and failed treatment with nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, and corticosteroid injections. X-rays of bilateral knees revealed mild to moderate tricompartmental osteoarthritis of the right knee and mild osteoarthritis in the medial compartment of the left knee. The patient reported worsening knee pain. Physical examination findings included tenderness to palpation of the knees with grinding on range of motion. The patient has requested authorization and coverage for Synvisc injections in both knees. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Synvisc injections in both knees are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. Researchers found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, there is a history of good results from prior viscosupplementation. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments with the alternative being bilateral total knee arthroplasties at a young age in the presence of mild to moderate osteoarthritis. The medical evidence supports the requested services in this clinical setting. Therefore, Synvisc injections in both knees are medically necessary for the 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.