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

A 60-year-old male enrollee has requested Harvoni for treatment of his hepatitis C virus.   Findings:  Three physician reviewers found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. In addition, the guidelines further indicate that Harvoni is recommended for treatment- naive patients with HCV genotype 1a infection. In this case, the patient has a HCV genotype 1a with a Metavir score of F2-F4 and is treatment naive. Therefore, treatment with Harvoni is medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a mechanical seat lift with a remote. The submitted documentation fails to demonstrate the medical necessity of the requested equipment. Durable medical equipment is defined as equipment which can withstand repeated use and is primarily and customarily used to serve a medical purpose. Additionally, durable medical equipment is appropriate for use in a patients home. Medicare guidelines indicate that in order to qualify for a mechanical seat lift, a patient should be unable to stand up from a regular arm chair and once standing should be able to ambulate. In this case, the records document osteoarthritis and rheumatoid arthritis of the back and lower extremities. The records do not document that this patient is incapable of standing up from a regular arm chair and that once standing she is able to ambulate. The medical evidence does not support the requested equipment in this clinical setting. Therefore, the requested mechanical seat lift with a remote is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Decision DX Melanoma Gene Assay testing performed for evaluation of her melanoma.  Findings:  Three physician reviewers found that the medical evidence does not support the services at issue in this patients case. There is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials according to published data available. Per the National Comprehensive Cancer Network guidelines, while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate benign from malignant neoplasms, or melanomas at low versus high risk for metastasis, routine (baseline) genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. In sum, Decision DX Melanoma Gene Assay testing performed was not likely to have been more efficacious than other methods of evaluating this patient. Final Result: Three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are 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

A thirty-one year-old female who has anorexia nervosa and depressive disorder is requesting authorization for residential treatment.  The patient has an enormous anxiety about eating and needed constant supervision to complete doing so.  Reviewers Findings:The reviewing physician found that the patients enormous resistance to eating requires the need for much more intensive treatment.  The reviewing physician concluded that the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 34-year-old male enrollee has requested surgical correction of damage sustained from previous scrotal abscess for treatment of his redundant prepuce and phimosis.   Findings:  The physician reviewer found that since the requested surgery is being performed to improve function, the requested surgery is reconstructive in nature. Further, the requested surgery is proposed to help to create as normal an appearance as possible with a penis that is not buried or retracted. Thus, the surgery is medically necessary and should be covered. The patient has already consulted with In-Plan surgeons who have deferred treatment to providers at a tertiary center. As the procedure will require the services of both a plastic surgeon and a urologist at the same time in the operating room, it is reasonable to authorize treatment by an Out-of-Plan urologist as well as an Out-of-Plan plastic surgeon as a team approach is required in these complex cases.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Corlanor for treatment of her medical condition. Findings:  The physician reviewer found that based on the records provided, the patient has Postural Orthostatic Tachycardia Syndrome (POTS)  and is unable to tolerate therapies that further lower blood pressure due to symptoms of presyncope. The optimal therapy of POTS has not been established, but it is generally recommended to avoid precipitating factors and to encourage physical activity in addition to volume repletion and fludrocortisone (0.05 to 0.2 mg per day) as first-line therapy, none of which should exacerbate hypotension. Some patients may benefit from midodrine, another therapy that would not exacerbate hypotension. The records provided do not document the patient has tried and failed any of the above treatment options. In addition, other therapies to treat POTS are controversial, including the use of Corlanor (ivrabradine). While there is some literature that has evaluated Corlanor in patients with inappropriate sinus tachycardia, this is a different patient population compared to patients with POTS syndrome.  In sum, the use of Corlanor for treatment of POTS has not been established as medically necessary.  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 sub-specialty 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: Overturned

Findings:  The physician reviewer found that The patient has requested reimbursement for inpatient services. The records reviewed indicate that although this patient did not develop complications due to the head injury such as low blood pressure or continued vomiting, the patient did have significant pain that required treatment in the hospital. In addition, the patient was found to have an intracranial hemorrhage, skull fracture, and cerebrospinal fluid (CSF) leak. These factors support that the patients presentation was consistent with a moderate traumatic brain injury. Per the American Academy of Neurology (AAN) guidelines, the patient required admission to the hospital to be monitored for complications that may have necessitated immediate intervention (Giza, et al.). Moreover, the inpatient treatment setting was appropriate to monitor the patients serum sodium and perform repeat computed tomography (CT) studies. All told, the inpatient services were medically necessary for treatment of 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.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old male enrollee has requested Rozerem for the treatment of sleep apnea and jet lag.Findings:  The physician reviewer found that Modafinil has an FDA approved indication for certain types of circadian rhythm disturbances - Rozerem does not. According to the FDA, Rozerem is indicated for the treatment of insomnia characterized by difficulty with sleep onset.  Although insomnia and circadian rhythm disturbances can present in similar fashions, they are distinct conditions. A search of relevant literature did not reveal any published studies utilizing Rozerem for circadian rhythm disturbances in humans. Although there is information suggesting the safety of this agent in patients with mild to moderate sleep apnea, no evidence of such a published trial was identified in a search of the published literature.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for the continuous airway positive air pressure (CPAP) machine for treatment of the enrollees obstructive sleep apnea. Findings:  The physician reviewer found that based on the current medical literature and the presented clinical records, the CPAP machine provided was and is medically necessary for treatment of the patients medical condition. The patient is diagnosed with OSA and has been prescribed CPAP for home use. CPAP is the standard of care for treatment of OSA of all severity levels. The current accepted standard of care with regards to CPAP is for a patient to have an initial three month trial of therapy with CPAP. It is after this initial 90 day window at which compliance with therapy is assessed. More specifically a patient is required to use CPAP device 70% or more nights for at least four hours a night within a specified 30-day period. In this case, the patient is noted to have been using the CPAP device near and above this threshold in both the early stages of therapy and the most recent CPAP compliance reports. In this circumstance, the records demonstrate that the patient has been compliant with CPAP therapy as defined by current literature. Given that the patient has shown compliance with CPAP, continued use of CPAP is medically necessary for the management of the patients OSA. Final Result: The reviewer determined that the device at issue was and 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 with sub-specialty certification in sleep 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 patient is a 47-year-old woman with multiple sclerosis (MS) and moderately spastic gait who currently requires no assistive devices to ambulate. She has requested authorization for a folding power operated vehicle (POV) to enhance her mobility. The submitted information includes no documentation of a trial of assistive devices such as a cane or walker. The Health Plan has denied the patients request on the basis the requested equipment is not medically necessary. Review of the submitted information does not demonstrate a POV is medically necessary for this patient. The patient has been noted to be ambulatory within her home. There is no evidence she requires mobility assistance equipment to ambulate. The patient does not meet nationally accepted medical necessity criteria for authorization of a POV. Therefore, I have determined the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old female has requested coverage for biofeedback therapy for treatment of her chronic pain.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested biofeedback therapy.  Van Tulder and colleagues performed a systematic review of available randomized controlled trials to determine whether behavioral therapy is more effective than reference treatments for chronic nonspecific neuromuscular pain and which type of behavioral treatment is most effective. They concluded that although behavioral therapy seems to be an effective treatment for patients with chronic low back pain, it is still unknown what type of patients benefit most from what type of behavioral treatment. Vlaeyen and Morley reported that there is relatively little known about the specific behavioral mechanisms that lead to chronic pain and pain disability.  At this time, the strength of evidence in the medical literature supporting biofeedback for chronic neuromuscular disorders is weak. The current medical evidence does not support the requested services in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee requested authorization and coverage of an ABI Vest for the treatment of asthma.  The health plan denied the enrollees request indicating that the requested equipment 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 equipment is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old female enrollee has requested prolotherapy for the treatment of her fibromyalgia. Findings:  Three physician reviewers found that prolotherapy (proliferant therapy) is based on the concept that scarring with formation of collagen after a pro-inflammatory agent is injected strengthens the ligamentous structures surrounding a joint. The treatment has been used for treatment of chronic musculoskeletal pain. However, there is limited high-quality data supporting the use of prolotherapy in the treatment of musculoskeletal pain. In particular, there do not appear to be any references in the medical literature discussing its use in fibromyalgia.
Appeal type: Medical Necessity
Decision: Overturned

An 18-year-old female enrollee has requested inpatient psychiatric hospitalization services for treatment of her major depressive disorder and post-traumatic stress disorder.  Findings:  The physician reviewer found that the patient stated repeatedly that she was not suicidal, but her behaviors often were suspicious. She admitted to her providers that she would not openly admit when she had thoughts of hurting herself. Therefore, it was important for the providers to consider her demeanor and behaviors. The provider noted that she remained in bed and refused to participate in group therapy and milieu activities. She was consistently described as quiet, sad, and feeling hopeless. Taken in its totality, these are warning signs of a person who might be suicidal, but tries to hide these intentions from providers in order to be discharged. On date indicated, the patient had a serious outburst of self-harm and stated that she had active suicidal thoughts. Overall, the records suggest the patient was not stabilized enough to return to a group home until she was discharged. For these reasons, the inpatient psychiatric hospitalization services were medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Norco. The Centers for Disease Control and Prevention (CDC) guidelines state that when opioid therapy is used, a patients regimen should include nonpharmacologic therapy and nonopioid pharmacologic interventions. Additionally, the CDC noted that, Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. The American Society of Interventional Pain Physicians (ASIPP) guidelines recommend providers to establish physical diagnosis and assess pain levels and disability to support medical necessity of treatment with opioids. In this case, the patient has chronic low back pain that is not concordant with his most recent lumbar magnetic resonance imaging (MRI). Evaluations have been performed by his pain management providers who advised against treatment with chronic opioid therapy. Based on the medical records provided for review and the current medical literature, the patient does not meet the criteria for treatment with chronic opioid therapy. Therefore, the requested Norco 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: Overturned

The parent of a 14-month-old female enrollee has requested cardiac catheterization procedure and associated surgery rather than cardiac surgery (and possible later catheterization procedure) for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted clinical documentation demonstrates that the patient needs relief of her right ventricular outflow tract obstruction (i.e., pulmonary stenosis). At issue is whether there should be an initial attempt to balloon dilate the pulmonary valve rather than to proceed with initial operative management. The proposed attempt at balloon pulmonary valvoplasty in the cardiac catheterization lab is medically appropriate as the initial procedure in this setting. If unsuccessful, surgical intervention can then be pursued. The proposed cardiac catheterization is less invasive and given the risks associated with surgery is medically reasonable and necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Zepatier for treatment of the enrollees chronic hepatitis C virus genotype 1b. The Health Plan has denied Zepatier on the basis that Zepatier is not medically necessary without documentation of failure of or contraindication to formulary alternatives including Harvoni and Sovaldi. Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that treatment-naive genotype 1b patients should be treated with regimens including Harvoni for 12 weeks or Zepatier for 12 weeks. These guideline recommendations are based on high-quality clinical trials for Harvoni and for Zepatier (Kowdley, et al; Afdhal, et al; Zeuzem, et al). However, there are no controlled direct-comparison trials showing that Zepatier is safer or more effective than Harvoni for treatment of genotype 1 hepatitis C. For these reasons, although treatment of hepatitis C is needed in this case, treatment with Zepatier for 12 weeks is not supported as medically necessary.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 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 patient is a 54-year-old male who worked as a roofer. He had surgery on his cervical spine and his lumbar spine. Post-operatively he continued to have severe pain that was not associated with loss of bowel, loss of bladder or other neurological findings. He was prescribed multiple pain medications with no significant reported improvement. He had injections in the facets of his lower spine but there was no reported improvement. After failure of Duragesic patches and Vicodin he was placed on methadone. He reportedly gave some of his medication to another individual and also had a urine analysis documenting his use of other opiates. Prior to being prescribed other opiates the patient was told that he had to attend a program offered by the Health Plan for chemical dependency. He was not compliant with this request. The Health Plan denied his request to start methadone again.The patient has chronic pain and is dependent on opiates. He was unable to follow the guidelines of methadone treatment and was discontinued from the program because of his escalation in the use of other opiates. The discontinuation of a long-acting opiate because of non-compliance is not unusual.It is clear that the patient experiences overwhelming pain from his orthopedic condition. His participation in the chemical dependency program remains a prerequisite for his receiving other opiates. Without his participation in this program, other treatments will not be effective.The denial of the request for methadone is medically appropriate. The need to offer a support program prior to starting other pain medications is customary and appropriate to the needs of the patient. Alternative pain management and the possibility of continuing opiates in a measured and controlled manner is an option after the patient shows full participation and compliance with the chemical dependency program offered by the Health Plan.Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.