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

The parent of an 11-year-old male enrollee has requested for aquatic physical therapy for treatment of the enrollees osteoporosis. Findings:  The physician reviewer found that there is a lack of long-term controlled studies on physical therapy for osteoporosis or chronic pain from metastases of lymphoma, there are studies that document good reduction in pain with short-term therapy. The patients physical therapist documented improved strength to near normal or normal and reported no pain at rest. However, the patient continues to have pain after periods of movement. Thus, pain reduction continues to be an active goal. Additionally, all of the patients physicians are in support of continued aquatic physical therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 51-year-old female with a long history of back pain. A discogram revealed degenerative changes at L4-L5. There is no documentation of radiculopathy. The patients physician reports the patient has tried and failed multiple treatment modalities including physical therapy, muscle relaxants, and nonsteroidal anti-inflammatory medication. At her physicians recommendation the patient is requesting authorization and coverage for percutaneous discectomy via radiofrequency ablation.Percutaneous discectomy via radiofrequency ablation is a procedure for radiculopathy secondary to continued disc protrusions. This patient has back and coccyx pain without any description of radiculopathy. The use of the proposed procedure in low back pain has not been evaluated in clinical controlled studies. As such, the efficacy of percutaneous discectomy via radiofrequency ablation for treatment of patients such as this patient has not been established. Accordingly, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 51-year-old female who has lumbar degenerative disc disease. The patient has attempted conservative therapies without sustained benefit. She has requested authorization for percutaneous discectomy via radiofrequency ablation. The Health Plan has denied this request on the basis the requested procedure is considered investigational.Percutaneous discectomy via radiofrequency ablation is not standard care for treatment of degenerative disc disease. There are no randomized, controlled trials demonstrating long-term efficacy of percutaneous discectomy. Furthermore, there is no peer-reviewed Class I data to suggest that percutaneous discectomy is a more effective treatment option for this patients condition than standard therapies. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 51-year-old female who has degenerative disc disease at L4-L5. The patient reports standard treatment has not been effective. She wishes to undergo percutaneous discectomy via radiofrequency ablation. The Health Plan indicates the long-term efficacy of the requested procedure has not been established.Percutaneous discectomy via radiofrequency ablation remains an unproven procedure. There is not sufficient peer-reviewed, blinded, controlled data supporting its efficacy. As such, percutaneous discectomy via radiofrequency ablation is without established clinical value. There is no Class I or long-term data to support the use of the proposed procedure for treatment of the patients low back pain. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for H.P. Acthar Gel corticotropin injection 80 units subcutaneously, three times a week.The submitted documentation fails to demonstrate the medical necessity of the requested medication. Based on the available information, symptomatic sarcoidosis is a presumptive diagnosis in this patient at the current time. Sarcoidosis is a diagnosis of exclusion, with a broad differential diagnosis, including mycobacterial/fungal infection, hypersensitivity pneumonitis, drug-induced hypersensitivity, pulmonary histiocytic disorders, foreign body granulomatosis, vascular inflammatory disease, and primary immunodeficiencies. Thus, the diagnosis of sarcoidosis necessitates a broader infectious, pulmonary, occupational/environmental and inflammatory work-up. In this case, there is insufficient data to support the diagnosis of sarcoidosis at the current time, particularly without a negative infectious work-up or tissue biopsy showing non-caseating granulomas.Moreover, in the setting of biopsy-proven sarcoidosis, current treatment guidelines do not recommend initial therapy with H.P. Acthar Gel. Glucocorticoids are generally recommended as first-line treatment for sarcoidosis. In those intolerant or unresponsive to glucocorticoids, intensification of therapy typically involves immunosuppressive agents, such as methotrexate, azathioprine, leflunomide, or tumor necrosis factor-alpha inhibitors. It remains unclear why this patient is unable to take immunosuppressive agents, in keeping with current guidelines, as poorly controlled diabetes is not a contraindication to such therapies. Therefore, H.P. Acthar Gel corticotropin injection 80 units subcutaneously, three times a week, is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat 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 pulmonary disease and critical care 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

A 54-year-old female enrollee requested authorization and coverage of a referral to an endocrinologist for the treatment of hypothyroidism.  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 services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for neuropsychological testing. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The records document borderline personality disorder, major depressive disorder and generalized anxiety disorder. The medical evidence does not support the need for neuropsychological testing for these diagnoses. There is some support for neuropsychological testing in the setting of brain injury. In this case, the records do not document brain injury. The patients reported symptoms included difficulty keeping a job and sleep issues. Per the standard of care, these symptoms may be appropriately treated with medication and psychotherapy. Therefore, neuropsychological testing was not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified psychologist 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

Epidural injections may be indicated for radicular pain that has not responded to at least six weeks of conservative care. The records provided for review do not document that the patient has participated in an adequate course of physical therapy and a home exercise program as recommended by her provider for her current complaints. The literature indicates that a home exercise program after physical therapy can provide a patient with long-term results without an epidural injection. In the absence of documentation that the patients condition has persisted following adequate conservative care, the requested foramen epidural injection (CPT codes 64483, 64484, 99213 and HCPCS code J1100), is 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 anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an eight-week course of Harvoni for treatment of her hepatitis C (HCV).  Findings:  Two physician reviewers found that the current medical evidence supports the requested medication in this clinical setting.  Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, the medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The evidence supports an eight-week course of Harvoni for non-cirrhotic patients with hepatitis C, genotype 1 with a viral load less than 6,000,000 IU/mL.  All told, the requested eight-week course of Harvoni is medically indicated for the treatment of this patient.  Final Result: Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are 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: Upheld

A 26-year-old female enrollee has requested residential treatment services for treatment of her alcohol dependence. Findings:  The physician reviewer found that the current minimum standard for this level of care (four weeks of treatment) was warranted for this patient. Continued residential services as of the date in question is not supported by the initial or additional documentation that has been submitted. Due to the fact that there is limited new medical information contained in the additional evidence provided, the initial determination remains unchanged. The new information provided consists entirely of letters that are dated well before the treatment period under review or after. One of the major predictors for a positive outcome when treating individuals with substance abuse problems is their level of motivation. These letters document that the patient had left treatment two previous times against medical advice. Thus, they demonstrate that the patient was not motivated to complete or cooperate in treatment, and as such, do not support the medical necessity of the disputed dates of service.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old male enrollee has requested Byetta for the treatment of his diabetes. Findings:  The physician reviewer found that Byetta is used with insulin in the endocrine community for management of patients such as this patient. It is likely the manufacturer will soon have FDA approval for concomitant use of Byetta with insulin as well. The proposed use of Byetta is medical reasonable and appropriate in these circumstances and should be authorized.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for excimer laser therapy. Ultraviolet light therapy is an established treatment modality for vitiligo. Excimer therapy is a targeted form of ultraviolet B (UVB) therapy, which has some advantages over traditional narrowband UVB including lower cumulative UV dose exposure and shorter course of therapy, as well as better-directed treatment at sites of skin pathology rather than compromising normal adjacent skin. Currently, excimer laser therapy is considered part of the standard of care for patients with vitiligo. In addition, there is ample data supporting the safety and efficacy of excimer laser therapy on the face when compared to tacrolimus. This patient also has a history of hypothyroidism, which has a known association with vitiligo. Moreover, clinical and wood lamp examination revealed findings consistent with vitiligo. Her providers have recommended treatment with excimer laser therapy. Given the support in the medical literature, the requested excimer laser therapy 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 55-year-old woman who was diagnosed with osteoporosis following a Lunar DEXA scan in February 2002. Subsequently, the patient was started on Evista with an apparent increase in bone mineral density of 3% at the lumbar spine and 5% at the hips 20 months later on a similar DEXA machine. Evista was then apparently discontinued sometime thereafter. A repeat scan seven months later revealed no essential change with a T-score of -3.3 at the hips, and a 2.1% increase to a T-score of -2.4 at lumbar spines L1-L3.The patient has declined the bisphosphonates suggested by the Health Plan and wishes to start Forteo. The Health Plan has denied the patients request indicating that Forteo is not medically necessary for treatment of the patients osteoporosis.Review of the relevant medical literature indicates the patient does not meet medical necessity criteria for Forteo. The submitted records indicate the patient has no fragility and no apparent risk factors beyond her T scores. In addition, there is no evidence the patient has failed all other treatments (such as bisphosphonates). Furthermore, the patient does not have very severe osteoporosis (usually defined as T-scores greater than -4.0) or other high risks for fractures such as old age, family history of hip fractures or smoking. The literature suggests Forteo should be reserved for women who meet one of the above criteria.If the patient does not wish to continue on Evista, a bisphosphonate is a reasonable alternative and is medically appropriate. There is no medical indication for use of Forteo at this time. Therefore, I have determined that the requested medication is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee requested vortioxetine (Trintellix). Findings: The physician reviewer found that the medication requested is medically necessary. Based on a review of the record, the reviewer found that this patient has been treated with Zoloft and Viibryd, but experienced side effects with both medications. As noted in the medical literature, Trintellix is efficacious in reducing depressive and anxiety symptoms in patients with major depressive disorder and high levels of anxiety and the current clinical trial data is suggestive of a benefit of vortioxetine in generalized anxiety disorder. Given the support in the medical literature and reported benefit by the patient, Trintellix, is medically necessary for the treatment of this patients depressive disorder and anxiety.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 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: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication, Harvoni 90-400mg, for 12 weeks. The enrollee was diagnosed 15 years prior with chronic hepatitis C virus (HCV); genotype 1a and is treatment naive. He also has a history of throat cancer and chronic myeloid leukemia. Laboratory results show a hepatitis viral load of 2,040,000 IU/mL. An ultrasound performed revealed a medial liver elastography of 4.6 kPa, corresponding to a METAVIR score of F0-1. Anti-viral resistance testing was done. This enrollee is Caucasian with a non-cirrhotic, chronic Hepatitis C genotype 1a infection. He is not subject to a short life expectancy that cannot be remediated with HCV treatment. According to current clinical guidelines and literature, Ledipasvir/Sofosbuvir (Harvoni) is a highly effective and safe treatment option for this enrollee. A clinical trial shows enrollees with HCV genotype 1 (GT1) who were treated with Harvoni achieved a sustained viral load (SVR), known as the treatment goal over 97%. However, considering the enrollees viral load is less than six million IU/ml, current literature supports Harvoni for eight weeks duration rather than 12 weeks duration. There is growing evidence that supports the comparable effectiveness of shorter treatment duration, eight weeks compared to the longer treatment duration, 12 weeks in terms of achieving the same sustained viral response (SVR) and treatment. Based on current literature on subgroup differences and response to treatment duration, medical guidelines for the treatment of HCV recommend eight weeks treatment of Harvoni be used for enrollees who are non-black, HIV-negative and have an HCV RNA level less than six million IU/ml. Based on literature, eight weeks treatment rather than 12 weeks of Harvoni is medically necessary for this enrollee. Final Result: The reviewer determined that the requested service is partially 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: Overturned

The parent of a 10-year-old male enrollee has requested Intuniv medication for the treatment of the enrollees medical condition. Findings:  The physician reviewer found that Intuniv is approved by the Food and Drug Administration (FDA) for the treatment of ADHD in children and adolescents 6-17 years of age. To date, the efficacy of Intuniv has been established in controlled trials (Sallee and colleagues) in more than one report. Intuniv is a long acting form of guanfacine (Tenex) and is not interchangeable with Tenex (Connor and colleagues). The authors state that, because of different pharmacokinetic guanfacine extended release is not substitutable on an mg for mg basis with immediate release guanfacine.  In addition, while commonly used off-label for treatment of ADHD, Tenex is an immediate release form of guanfacine and does not have FDA approval for ADHD. In addition, Tenex carries the risk of hypertensive crisis if stopped abruptly. Thus, it would not be in the patients best interest to discontinue Intuniv for a trial of Tenex when Intuniv which has been beneficial for the patients medical condition. For these reasons, the records provided have established the requested medication as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lap-band removal and gastric bypass surgery for treatment of the enrollee, who is status post Lap-band placement. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services. The Lap-band is a mechanical device which has a high explant rate secondary to complications related to the device, failure of the device to result in intended weight loss and/or intolerance to the device. This patient has worsening gastroesophageal reflux disease.  Per the medical records, she requires Lap-band removal to prevent secondary complications of prolapse, erosion and slippage. Therefore, the requested Lap-band removal is medically necessary for the treatment of this patient.  However, the medical necessity of gastric bypass surgery cannot be determined at this time. There is a lack of documentation of a recent multidisciplinary evaluation, including a detailed dietary evaluation, documentation of understanding of micronutrient deficiencies, as well as a psychological evaluation that documents understanding of revisional surgery and increased risks. At this time, the records do not document complications of the Lap-band that require emergent surgical intervention with conversion to gastric bypass that would preclude completion of an updated multidisciplinary evaluation. The last evaluation was completed prior to the Lap-band 7 years ago. There is no record of either the original multidisciplinary evaluation or an updated multidisciplinary evaluation specifically in regards to this patient as a candidate for revisional surgery. Therefore, the requested gastric bypass surgery is not medically necessary for the treatment of this patient. All told, a portion of the requested services (Lap-band removal) is medically necessary for the treatment of this patient. Final Result: The reviewer 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: The reviewer is board certified in surgery with expertise in 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.