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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Harvoni. Findings:  The physician reviewer found that according to the recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America (AASLD/IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). The guidelines recommend that non-cirrhotic treatment naive genotype 1 patients should be treated with Harvoni for 12 weeks or Zepatier for 12 weeks (if there is no NS5A resistance). The guidelines recommend either Harvoni or Zepatier as acceptable therapy. However, there is a need for NS5A resistance testing prior to Zepatier in genotype 1a patients. No medical contraindication to Zepatier is reported in this case. For these reasons, treatment of hepatitis C is needed, but the requested treatment with Harvoni is only supported as medically necessary for the treatment of this patients hepatitis C infection if Zepatier is unavailable. Therefore, Harvoni is not medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication regimen is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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

A 39-year-old female enrollee requested authorization and coverage of an abdominal dermatolipectomy. The Health Plan denied the request indicating that the requested procedure is considered cosmetic in nature and therefore is not medically necessary for treatment of the enrollees abdominal pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is cosmetic in nature and not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested authorization and coverage for surgical insertion of interspinous process spacer. At this time, there is a lack of high quality evidence to support the use of interspinous spacer devices in lieu of laminectomy, which remains the gold standard for lumbar spinal stenosis. The 2011 clinical guidelines from the North American Spine Society (NASS) suggest that there is insufficient evidence to make a recommendation for or against the placement of an interspinous process spacing device in patients with lumbar spinal stenosis. In this case, the patient presents with lumbar stenosis and neurogenic claudication. The guidelines support laminectomy in this clinical setting. Based on the current medical literature, the requested surgical insertion of interspinous process spacer is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested surgical insertion of interspinous process spacer is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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: Physician reviewers 1, 2, and 3 are board certified in orthopedic 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 36-year-old female enrollee requested authorization and coverage of the medication Sporanox. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees fungal sinusitis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for Rituxan 10 mg injections. The submitted documentation supports that the requested medication is medically necessary. Multifocal motor neuropathy is a treatable immune disorder of the peripheral nerves that is characterized clinically by slowly progressive or stepwise asymmetric, distal more than proximal, upper more than lower limb, weakness in multiple motor nerve distributions. The patient has been diagnosed with multifocal motor neuropathy. The patients EMG studies demonstrate multifocal motor demyelination, specifically partial motor conduction block, and her laboratory results show evidence of high serum anti-GM1 IgM antibodies. The patients Neurologist has noted that the patient has received IVIG treatment but has had an inadequate response and has continued to decline. Under these circumstances, Rituxan 10 mg injections are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested a Positron Emission Tomography (PET) scan for an evaluation of her ovarian cancer. Findings:  Two physician reviewers found that although PET scan has been proven useful for the detection of tumor recurrence, in this case, the CT scan showed findings indicative of the diagnosis so that PET scanning was not necessary to document metastatic liver disease. Thus, although the customary practice of an oncologic work-up for tumor staging typically includes PET scans, the ordinary follow-up CT in this case provided enough information to make the diagnosis of metastatic disease within the liver without the benefit of information derived from the PET scan.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested inpatient psychiatric hospitalization for treatment of his behavioral health condition.  Findings:  The physician reviewer found that psychotic illnesses are chronic conditions that commonly demand multiple psychiatric hospitalizations over the course of a lifetime. However, psychiatric interventions provide a realistic expectation for meaningful recovery, allowing patients to live independently in the community of their choosing. In this case, the patient has not decompressed the symptom burden that prompted the admission and is not stable for transition to a less restrictive treatment setting. Further, he remains engaged in active treatment that is reasonably expected to improve his condition and prevent a more serious episode of illness. In addition, both the clinical care and treatment setting was and is safe, appropriate and consistent with good medical practice.  Thus, the services at issue were and are medically necessary for treatment of the patients behavioral health condition. Final Result: The reviewer determined that the services at issue were and 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 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 coverage for OxyContin 15 mg, twice daily for treatment of the enrollees knee pain. Findings:  The physician reviewer found that there is a lack of support for the requested medication in this clinical setting.  Per the records, non-opioid treatment options have not been exhausted in this case.  The records do not document that behavior therapy has not been discussed or completed despite significant research to support its use.  Additionally, the records indicate that tolerance has taken place since the start of the narcotics.  Dose escalation is not a long-term plan, but a short-term plan for the treatment of tolerance.  Per the literature, there is the possibility of opioid induced hyperalgesia in this setting.  In this patients case, there is no clear objective functional goals for the additional opioids being prescribed.  For all these reasons, the requested OxyContin 15 mg, twice daily 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 physician reviewer is board certified in anesthesiology with sub-specialty certification in pan 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 AmniSure testing for evaluation of the enrollees pregnancy. Findings: All three physician reviewers found that this patient presented with concern of rupture of membranes. Traditional testing in this setting includes three elements from an evaluation of vaginal fluid: ferning, nitrazine testing and pooling.  Tests such as AmniSure testing have been shown to have higher false positive rates. The current medical evidence supports the use of AmniSure testing in cases where traditional testing is equivocal or the situation is high-risk. In this case, the patient presented with no risk factors that would make using traditional testing to rule out rupture of membranes unsatisfactory. There is no indication in the medical records that a traditional evaluation was conducted or was inconclusive. Final Result: The 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: Reviewers 1, 2, and 3 are board certified in obstetrics and gynecology 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 fifty-nine year old male with a progressive high frequency sensorineural hearing loss is requesting reimbursement for a Neuromonics Tinnitus Training program.Reviewers Findings:  The reviewing physician found that the safety and efficacy of the Neuromonics Tinnitus Training program has not been sufficiently established. Studies conducted to date have only involved a small number of subjects and these studies have been open.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 36-year-old female enrollee has requested transcranial magnetic stimulation for treatment of her major depressive disorder.  Findings:  Two physician reviewers found that in this case, the submitted clinical information fails to establish that transcranial magnetic stimulation is likely to be superior over other available treatment options. The details of past antidepressant trials in terms of dose, length, degree of compliance, side effects, and response are not noted in the material supplied. Furthermore, there is insufficient data to ascertain that variables which could have adversely affected her prognosis, such as comorbid Axis II conditions, substance abuse and/or psychosocial stressors, have been investigated and addressed. American Psychiatric Association guidelines indicate that electroconvulsive therapy is the most effective treatment for depression. Eranti and colleagues noted the superiority of electroconvulsive therapy over transcranial magnetic stimulation.  Martin and colleagues indicated that there is insufficient evidence regarding the efficacy of transcranial magnetic stimulation to warrant its use in standard practice.  Based upon the current medical evidence, in this clinical scenario, the superior efficacy of transcranial magnetic stimulation has not been established.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a nine-year-old female enrollee has requested for Humira for treatment of the enrollees juvenile rheumatoid arthritis. Findings:  The physician reviewer found that while the FDA has not approved Humira for patients under the age of 18 year, the drug is approved for rheumatoid arthritis and there is an application by the manufacturer in process with the FDA to extend approval to children. In addition, ongoing studies are being conducted (e.g., Dr. Dan Lovell in Cincinnati) that indicate benefit in children. Furthermore, the pediatric rheumatology community is using Humira in children who resistant to other therapies.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for anesthesia services provided her routine colonoscopy. Researchers note that the overall risk of complications after colonoscopy increases when individuals receive anesthesia services. In this case, the patient underwent a routine colonoscopy. She was noted as ASA Class 2, with a Mallampati score of 2. She had a BMI of 22.2, and as such was not morbidly obese and was unlikely to present as a difficult airway to manage. The literature does not support the use of monitored anesthesia care in a patient who does not have significant health conditions or airway concerns. Rather, the guidelines suggest there is high quality evidence to support the use of mild to moderate sedation in healthy, uncomplicated endoscopy procedures, such as in this case. Based on the current medical evidence, the services at issue were not medically indicated. Therefore, anesthesia services provided during the patients routine colonoscopy were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service 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 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for physical therapy, occupational therapy, and speech therapy provided at a skilled nursing facility (SNF). Functional impairments due to a cerebral stroke can be severe to profound. Functional recovery may be amenable to natural recovery processes and rehabilitative measures. However, the extent of initial injury generally determines the patients capability of engaging in recovery (Alawieh, et al.). Most of a patients significant neurological and functional recovery following a stroke occurs in the early stages after stroke, such as in the first 30 days, and gains are slower in the subsequent stages (Kubis). There is a general consensus that initiating intensive rehabilitative measures earlier in the post-stroke course enhances outcomes, but there is a lack of data guiding optimal practices regarding dose, manner, and venue of stroke rehabilitation in the more subacute and chronic stages (Belagaje; Gittler and Davis; Stinear, et al.). In the present case, the patient sustained a stroke in February 2022 following CABG surgery. The patient has undergone extensive rehabilitation efforts with therapy, but he has remained at a low level of function and continues to require maximum to total assistance for most basic self-care and mobility. The records indicate that the patients persistent left-sided hemiplegia has been a barrier to progress. The patient has remained at a custodial level of care and there is a lack of support for the requested therapy services in a SNF treatment setting. Therefore, the requested physical therapy, occupational therapy, and speech therapy provided at a SNF are not medically necessary for treatment of this patient. 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing. While lipoprotein subparticles have associated with increased cardiovascular risk, under current American Heart Association (AHA) and American College of Cardiology (ACC) guidelines for the management of cardiovascular risk note that low-density lipoprotein (LDL) is the main target of lipid lowering therapy to decrease the risk for adverse cardiovascular events. In this case, the results from the advanced lipoprotein testing at issue would not have altered patient management or the recommendation for statin therapy. Therefore, advanced lipoprotein testing was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology and is actively practicing. Physician reviewers 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Overturned

At issue is whether the requested medication, Emgality 120mg/ml pen injector is medically necessary to treat the patients medical condition. This is a patient that has been diagnosed with chronic migraines since childhood. The provider indicated that with Botox injections, this patients migraines have reduced. Prophylactic medications tried include topiramate, amitriptyline, and propranolol. Abortive medications include Sumatriptan, ibuprofen and Vicodin. A letter of medical necessity from the provider detailed that with the addition of Emgality, the patients migraine days have reduced per month and are less intense. The reviewer states that Emgality, in clinical trials, has been demonstrated to reduce the frequency and severity of medical refractory migraine headaches. In a recent clinical study, there was clinical benefit (without adverse side effects) with concurrent use of Botox injections with inhibitors such as Emgality. In this case, given the patients medical history and recent clinical studies, the combination of Botox and Emgality together is warranted and medically appropriate for this patient. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in neurology       and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a computerized axial tomography (CAT) scan of the head, magnetic resonance imaging (MRI) of the neck, MRI of the knees and MRI of the feet for evaluation of her medical condition.  Findings:  The physician reviewer found that there is a lack of support for the requested services in this clinical setting.  This patient has had chronic symptoms referable to her wrists.  In this case, the most appropriate consultations that the patient has had have been with the rheumatologists.  She has had extensive evaluation, and there has been no indication that she had a systemic process that would warrant advanced testing.  She has also not had basic imaging such as x-rays of the knees, cervical spine, or feet. This patient has no symptoms or signs indicating that there is a structural brain abnormality.  While CAT scans of the brain may be performed for ill-defined symptoms, the yield on those studies is exceedingly low.  There is a lack of support for the requested services in this clinical setting.  All told, the requested CAT scan of the head, MRI of the neck, MRI of the knees and MRI of the feet are not medically indicated for the evaluation of this patient. Final Result: The reviewer determined that the requested services are 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 in diagnostic radiology 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 23-year-old female enrollee requested authorization and coverage of a CT scan of the head. The Health Plan denied the request indicating that the requested CT scan is not medically necessary for evaluation of the enrollees headaches.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested CT scan is not medically necessary.