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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for eight weeks for treatment of her chronic hepatitis C virus genotype 1a. Two physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. The fixed dose combination ledipasvir-sofosbuvir (Harvoni) is FDA approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. Therefore, the requested Harvoni is supported as medically necessary for treatment of this patients chronic hepatitis C virus. 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are 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: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee requested authorization and coverage of re-treatment with PEG-Interferon and ribavirin. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees hepatitis C.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for compounded ketamine with lidocaine, baclofen, gabapentin and cyclobenzaprine.  Colleagues noted potential benefit for use of topical compounded cream for complex regional pain syndrome but found no benefit greater than oral administered therapies. In the absence of demonstrated contraindication or intolerance to oral and parenteral medications there was no improved benefit.  Colleagues noted there were no controlled trials of sufficient size and power that showed statistical significant benefit from the use of compounded creams containing ketamine for complex regional pain syndrome (CRPS). Colleagues also noted no statistical benefit of ketamine topical creams for treatment of CRPS compared to standard therapies.  All told, the use of compounded creams has not shown significant benefit in controlled trials for treatment of CRPS. Such compounded creams are not standardized in terms of the amount, strength or type of contents. Combination of compounds in one cream is not comparable to the use of one medication topical compounds due to the unknown nature of synergistic or conflicting properties of the compounded combination.  Studies have not demonstrated any benefit compared to standard treatments. Furthermore, the submitted records do not demonstrate intolerance to standard treatments or contraindication to standard treatments. In sum, the requested compounded ketamine with lidocaine, baclofen, gabapentin and cyclobenzaprine compounded medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: All three reviewers determined that the requested compounded medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One Reviewer is board certified in pain management and anesthesiology and is actively practicing. One Reviewer is board certified in pain management and anesthesiology and is actively practicing.  One Reviewer is board certified in pain management and 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret. According to the most recent joint guidelines, 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. 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 infection regardless of fibrosis stage. Guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the Afirma gene test for evaluation of her medical condition.  Findings:  Three physician reviewers found that molecular testing or gene expression classifier has been proposed as an adjuvant in medical decision making of whether to refer a patient for thyroidectomy. The American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer guidelines indicate For nodules with [atypia of undetermined significance/follicular lesion of undetermined significance] AUS/FLUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat [fine needle aspiration] FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision-making. In this case, the patient had a minimally enlarging nodule. The Afirma gene expression classifier was consistent with benign results. The risk of malignancy is decreased to 2.5%, per ATA guidelines. A benign result prevented an unnecessary surgery and its potential comorbidities (Alexander, et al; Duick, et al). Surgery is not necessary with this result and continued observation is recommended. Therefore, the Afirma gene test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the testing at issue was 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:   All three reviewers are board certified in internal medicine with sub-specialty certification in endocrinology and metabolism and are 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: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee has requested budeprion XL 450mg per day and sertraline 200mg per day for treatment of her depression. Findings:  The physician reviewer found that this is a rational medication combination for the treatment of depression based on American Psychiatric Association guidelines. The dosages are consistent with the maximum recommended dose and are not considered excessive for a patient with severe depression. In sum, the medication dosages at issue were medically appropriate and necessary in this setting and consistent with treatment guidelines.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for IVIG (intravenous immune globulin) therapy with Gammunex-c/Gammaked. Findings: Two of the three physician reviewers found that the requested therapy is not indicated under these circumstances. In this case, there is no clear evidence that the patient has a post-infectious encephalopathy. The patient is not reported to be encephalopathic, and has had no altered consciousness, seizures or other neurological symptoms. There is also no documentation that the patient has had a lumbar puncture or neuroimaging in the form of an MRI of the brain to investigate whether the patient has any acute neurological process. The patients autoantibodies were noted to be negative. The patient does not appear to have had standard psychiatric treatments for obsessive compulsive disorder, anxiety and depression such as cognitive behavioral therapy or a consistent trial of psychotropic medication. Therefore, IVIG therapy with Gammunex-c/Gammaked is not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy.Final Result: The reviewers determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewer 1 is board certified in pediatrics and in allergy and immunology, and is actively practicing. Physician reviewer 2 is board certified in pediatrics, with subspecialty certification in pediatric infectious diseases, and is actively practicing. Physician reviewer 3 is board certified in pediatrics and in neurology with special qualification in 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: Overturned

An enrollee has requested reimbursement for negative pressure wound therapy treatments. Negative pressure wound therapy has rapidly gained acceptance as a preferred approach to treating complex wounds in both diabetic and non-diabetic patients. In this case, the patient presented with a large wound on the right buttock where expedited healing is a priority. Although limited, the current medical literature has provided data showing accelerated and improved healing with negative pressure wound therapy for use in this patient. All told, the negative pressure wound therapy treatments were likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found that the negative pressure wound therapy treatments were likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in surgery 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 62-year-old female enrollee requested viscosupplementation injections (series of three) for treatment of the enrollees osteoarthrosis of the knee.  Findings:  The physician reviewer found thatThe current medical evidence does not support the requested services in this clinical setting.  There have been carefully conducted double-blinded studies which do not document any clinical effect from hyaluronan injection.  Additionally, there is a documented incidence of aseptic inflammatory reactions due to allergic response.  This patient has had multiple injections and with each injection and exposure to the antigen, there is an increased risk of allergic response.  There is also a risk of iatrogenic infection within the joint.  Rutjes and colleagues performed a systematic review and meta-analysis of the efficacy of viscosupplementation.  The authors concluded that in patients with knee osteoarthritis viscosupplementation is associated with a small and clinically irrelevant benefit.  The authors also noted an increased risk of serious adverse effects.  All told, the requested viscosupplementation injections (series of three) are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xanax 2 mg, 1 tablet every 8 hours, not to exceed 6 mg per day, 90 tablets per month. In this case, the records indicate that the patients primary medical diagnosis is lumbosacral disc disease, with refractory back pain. Given the patients upcoming revision of lumbar fusion, pain medication may become a priority for the patients ability to function and maintain a quality of life. The combination of opioids with a benzodiazepine is contraindicated. Additionally, the requested dosage of Xanax is above what is recommended by the U.S. Food and Drug Administration (FDA). The FDA notes a maximum daily dose of 4 mg for the treatment of patients with anxiety. In this case, the records note that the patient is on a starting dosage of sertraline. It is likely that with an appropriate titration of sertraline, the patient will not require the requested dosage of Xanax. Given that benzodiazepines are not indicated for the long-term treatment of depression or anxiety, the requested medication is not medically indicated. In this patients case, Xanax 2 mg, 1 tablet every 8 hours, not to exceed 6 mg per day, 90 tablets per month is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested medication is not clinically appropriate in terms of type, frequency, extent, site, and duration. The requested medication is primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, Xanax 2 mg, 1 tablet every 8 hours, not to exceed 6 mg per day, 90 tablets per month is not medically necessary for the 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 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 reimbursement for Carac 0.5% cream for treatment of the enrollees actinic keratosis. Findings: The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the medication at issue. This patient has been diagnosed with actinic keratosis, and she has tried and failed therapy with Picato. The Health Plan coverage criteria requires a treatment trial and failure of generic fluorouracil cream, generic fluorouracil solution or generic imiquimod cream prior to coverage of brand name Carac. These medications are useful for the treatment of pre-cancerous actinic keratosis, which has the potential to develop into squamous cell carcinoma if untreated. Thus, there were other effective, preferred formulary agents for the treatment of this patients condition. Therefore, Carac 0.5% cream was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the medication at issue was 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.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 32-year-old female with a body mass index (BMI) of 40.5 and comorbidities including hypertension and obstructive sleep apnea. She has failed medical management of her obesity and wishes to undergo weight loss surgery. The patient and her provider believe the Lap-Band is the most appropriate procedure for treatment of her obesity. The Health Plan has denied authorization and coverage for Lap-Band surgery.The Health Plans denial should be upheld. Based upon the submitted nutritional analysis, it appears the patient does not make appropriate food choices, has failed numerous diets, and does not control portion sizes. Furthermore, the patient is quite young. Patients such as this patient often fail gastric restricted procedures like the Lap-Band and may not tolerate a foreign body for 40 to 50 years. A restrictive/malabsorptive approach is more medically appropriate in this clinical setting and is likely to be more effective. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 25-year-old female has requested the Nuss procedure for treatment of her recurrent pectus excavatum.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested procedure in this patients case.  This patient is likely to benefit from a successful Nuss operation.  With decreased sternal deformity, she is likely to experience improvement in her symptoms.  The Nuss procedure has been successfully performed on adults who have failed prior Ravitch procedures.  In this patients case, the paucity of tissue of the chest wall and the poor healing quality of tissues associated with Ehlers-Danlos syndrome may increase the risk of surgery.  However, per the submitted documentation, a surgeon has expressed willingness to proceed with the operation despite the risk.  The current medical evidence supports the requested procedure in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for axillary lymph node biopsy.The patients lymph nodes have not changed significantly over a two-month interval. However, it is appropriate for the patient to undergo a biopsy in an attempt to determine the etiology of the enlarged lymph nodes. The mammogram and ultrasound revealed that some of the patients lymph nodes measure up to 1.5 cm, which is abnormal. Evaluation with lymph node biopsy to confirm or rule out pathologic abnormality including inflammatory, infectious, or malignant processes is consistent with the recommendations in current medical literature. All told, the requested axillary lymph node biopsy is medically necessary for further evaluation and 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 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage Nutropin AQ Nuspin 20 solution pen injectable, 20 mg/2 mL. The essential criteria for human GH to treat isolated pediatric growth hormone deficiency are a height z-score two standard deviations (SDs) below the mean for age and gender as well as open epiphyses prior to initiation of GH therapy. This patients height prior to initiation of GH therapy was within normal range. Moreover, based on her bone age and height prior to GH therapy, the patients predicted adult height was within normal range. Since provocative GH tests can yield false failures for multiple reasons, such provocative tests are not the sole diagnostic criteria for isolated pediatric growth hormone deficiency. Patients with isolated pediatric growth hormone deficiency do not display predicted adult height within the normal range. Based on the available documentation, this patient does not meet the criteria for growth hormone deficiency. For these reasons, the requested Nutropin AQ Nuspin 20 solution pen injectable, 20 mg/2 mL 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 pediatrics with subspecialty certification in pediatric endocrinology 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.