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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient hospitalization services. Findings:  The physician reviewer found that Based on the available documentation, the inpatient hospitalization services provided to this patient were medically necessary for the treatment of left ovarian torsion. As noted in the medical literature, ovarian torsion is considered a gynecological emergency that requires prompt surgical attention in order to preserve the function of the ovary and prevent future complications of pain, adhesions, and infertility. This patient presented to the emergency department for an emergent medical condition. The patients care was delayed due to the attempt to transfer her to another hospital. Once the patient underwent laparotomy, her post-operative course was uneventful. Remaining in the hospital for one day post-operatively is consistent with current recommendations and medical literature to assure that the patient has met all of her goals of diet, pain, and ambulation prior to discharge. For these reasons, the inpatient hospitalization services provided 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. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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 has requested authorization and coverage for Zepatier 50-100 mg tablets for a duration of 12 weeks for treatment of the enrollees hepatitis C virus. 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). This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1b patients should be treated with regimens including or Zepatier for 12 weeks, based on clinical trial results showing a 99% cure rate regardless of NS5A resistance. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 50-100 mg tablets for a duration of 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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 52-year-old female enrollee has requested for Genotropin for treatment of her adult growth hormone deficiency (AGHD).   Findings:  The physician reviewer found that the current gold-standard test is insulin-induced hypoglycemia. An inadequate response of growth hormone to insulin-induced hypoglycemia is diagnostic of AGHD.  Alternatively, testing with the combined administration of growth hormone releasing hormone (GHRH) plus arginine testing can achieve comparable separation between normal and hypopituitary subjects.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 58-year-old male diabetic with onychomycosis involving the nails in his hands and feet. The patients provider notes the patient was unable to tolerate Lamisil due to gastrointestinal upset. A request has been made for Penlac. The Health Plan has denied authorization for Penlac on the basis that it is not medically necessary for treatment of the patients onychomycosis. In light of the patients immunosuppressed status and increased risk for secondary bacterial infection, his onychomycosis should be treated. Both Lamisil and Sporanox appear to be contraindicated secondary to the patients concomitant medical problems and medications. Though topical Penlac is generally less effective it is an appropriate alternative in this case pending laboratory confirmation of fungus with KOH, CX or PAS stain.Based upon the information set forth above, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. Laboratory confirmation of fungus should be obtained prior to authorization of Penlac.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee requested authorization and coverage of a gastric bypass with duodenal switch for the treatment of morbid obesity.  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 surgery is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female has requested integrated pain management for treatment of her Crohns disease and pain disorder.  Findings:  The physician reviewer found that Currie and colleagues published a study describing outcome evaluations of a pain management program adapted to the needs of patients diagnosed with concurrent pain and substance abuse disorders. The authors concluded that patients with concurrent chronic pain and recovering substance abuse were responsive to an integrated treatment model of pain management and relapse prevention. The patient in this case is more likely to benefit from an integrated pain management program if she works toward abstinence from cannabis. Chelminski and colleagues performed a clinical trial to evaluate the effectiveness of a multi-disciplinary pain management program for opioid-treated patients with psychiatric co-morbidity and disability. The authors concluded that a primary care disease management program improved pain, depression, and disability scores over three months in a cohort of opioid-treated patients with chronic non-cancer pain. Effective care of patients with chronic pain should include rigorous assessment and treatment of these comorbid disorders and intensive efforts to follow-up. The patient has multiple medical problems, including psychiatric disorders. Consistent with these findings, the requested integrated pain management program is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested a mammogram without radiation (i.e. ultrasound, magnetic resonance imaging, thermography, or electrical impedance scanning) for evaluation of her cluster of microcalcifications in the left breast.  Findings:  The physician reviewer found that this patient has microcalcifications detected on screening mammography. The next procedure of choice will be to magnify the calcifications using traditional digital mammography. This additional technique will allow the radiologist to determine if the calcifications are suspicious enough to warrant biopsy. If so, the next technique will be to perform a stereotactic biopsy using mammographic technique. Thus, at this time, MRI is not suitable in this case due to the less than perfect negative predictive value of the imaging study in this setting. In addition, ultrasound is inadequate since microcalcifications often are not seen with this technique. The primary concern in this case is whether the microcalcifications seen on mammography represent ductal carcinoma in situ (DCIS). To acquire this data, the only reliable means with which to evaluate the breast is traditional mammographic magnification views and if necessary following this evaluation with core biopsy using stereotactic mammographic guidance. The other options suggested by the patient are not endorsed by the scientific community and are not supported by the relevant medical literature as medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Euflexxa injection series in the left knee.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patients options are limited. The patient has tried and failed other conservative treatments with the alternative being a total knee arthroplasty. Therefore, the requested Euflexxa injection series in the left knee is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested surgery (hemorrhoidectomy) for treatment of the enrollees painful hemorrhoids. Findings: The physician reviewer found that an enrollee has requested authorization and coverage for surgery (hemorrhoidectomy). The Health Plan has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees painful hemorrhoids.  The requested surgery has not been established as medically necessary for treatment of the patients medical condition. Hemorrhoids are part of the normal anorectal anatomy and symptoms from hemorrhoids are common. The records do not include examination of the anal area, digital rectal exam and anoscopy. Initial medical management includes increasing the fiber in the diet and minimization of time spent with each bowel movement. If a patients symptoms do not improve with conservative medical management, then office based procedures such as rubber band ligation should be considered (Jacobs). The American Society of Colon and Rectal Surgeons (ASCRS) practice parameters for management of hemorrhoids states that the evaluation of patients with hemorrhoids should include a directed history focusing on symptoms, bowel habits, family history, and physical exam such as visual inspection, digital exam and anoscopy. In this case, there is no medical documentation to support that these were performed for this patient. The practice parameters also state that dietary modification with adequate fiber and fluid intake is the first-line non-operative therapy for patients with symptomatic hemorrhoids. Finally, the ASCRS further states that patients with grade I, II, or III hemorrhoids that fail medical management may be effectively treated with office-based procedures. Similar recommendations for initial diagnosis and management of hemorrhoids are made by the American College of Gastroenterology (Wald, et al). Given the lack of documentation showing history and physical examination, as well as trial and failure of conservative medical management, the request for hemorrhoidectomy is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested surgery 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 certified in colon and rectal 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

The parent of a 16-year-old female has requested coverage for past laser surgery for treatment of her cafe au lait macules/patch in the periorbital region.  Findings:  The physician reviewer found that the patient has documented cafe au lait macules of the periorbital region. Although the patients parent expressed concerns regarding the patients vision being affected in the future, this is not supported by the documentation provided. Additionally, the medical documentation does not support any functional deficits as a result of the patients medical condition and therefore the medical necessity of the patients laser surgery has not been established. With regard to whether the patients laser surgery was reconstructive in nature, cafe au lait macules are a condition of focal hyperpigmentation in a relatively defined lesion and thus can be considered an abnormal structure. Additionally, the patients condition is a congenital abnormality that has been present since an early age. However, this condition does not result in any functional deficit for this patient. Further, although the patients appearance is affected by her condition, recent pre-procedure photographs have not been provided and it does not appear that the laser surgery would have resulted in more than a minimal improvement in the patients appearance based on the documentation provided. As such, the submitted documentation does not demonstrate the patients laser surgery was reconstructive in nature.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested Xyrem for treatment of sleep disturbance and pain associated with fibromyalgia.  Findings:  The physician reviewer found that review of the relevant medical literature does not support the use of Xyrem for the treatment of fibromyalgia. Xyrem is an agent with definite addiction possibilities, as well as concerns about abuse in non-therapeutic circumstances. It also has significant risks related to depression, both during treatment and following withdrawal. Xyrem has only been approved for use in treating a specific diagnosis (narcolepsy with cataplexy), which this patient does not have. There is very limited data from two short-term studies in patients with fibromyalgia which report favorable results. Longer-term studies are needed and are said to be underway. The current body of evidence supporting the use of Xyrem for treatment of fibromyalgia is inadequate to demonstrate long-term efficacy or safety. Use of this drug to treat fibromyalgia is not within standard practice at this time. This patient has reportedly been treated with numerous agents intended to treat fibromyalgia, but it is unclear from the provided list of agents whether full or adequate trials were undertaken. Given the lack of proven efficacy of Xyrem in this setting, further attempts with standard agents would be more appropriate in this case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for arthroscopy with femoroplasty and labral repair (CPT codes 29914 and 29916). This patient presented with left groin pain after a motor vehicle accident that was rated moderate to severe and did not resolve with three months of conservative treatment. Imaging revealed CAM type femoroacetabular impingement with a pistol grip type deformity. She did not have osteoarthritis or other contraindication to surgery. She underwent arthroscopy of the hip and was found to have chondrolabral separation with wave sign in zone II and zone III of the acetabulum that was repaired with suture anchors. In addition, there was a CAM type impingement that was corrected. The provider noted the presence of a pistol grip deformity of the proximal femur, which is known to be a cause of osteoarthritis, and starts as a tilt deformity and progresses to the pistol grip, then eventually cam-type femoroacetabular impingement. A review of the literature pertaining to CAM type femoroacetabular impingement reveals appropriate indications for surgery were present in this patients case. Moreover, the operative procedure of femoroplasty, and labral repair was appropriate for management of the left hip pain with labral tear and femoroacetabular impingement of the patient. All told, the left hip arthroscopy with femoroplasty and labral repair (CPT codes 29914 and 29916) was 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. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for consultation with a bariatric surgeon for evaluation of the enrollees morbid obesity. Findings:  The physician reviewer found that there is support in the medical literature for the medical necessity for a consultation with a bariatric surgeon in this clinical setting. The patients diagnosis of morbid obesity is confirmed by her weight and her BMI of 41.9 kg/m2. The medical necessity of bariatric surgery is still not determined at this point, as there is no documentation of a multidisciplinary evaluation which would include a dietary evaluation and psychological evaluation. However, a referral to a bariatric surgeon to begin this process of evaluation is appropriate and medically indicated. All told, the requested consultation with a bariatric surgeon is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for Enhertu (fam-trastuzumab deruxtecan-nxki) infusions. This patient has stage IV adenocarcinoma of the rectum. She has been treated with extensive standard care options. The patient underwent next generation sequencing, which revealed the patients tumor is microsatellite stable, with amplification of RAS, BRAF, WT, and HER2. Given the finding of HER2 amplification in the setting of wild type RAS and BRAF sequences, the provider recommended treatment with Enhertu. According to the National Comprehensive Cancer Network (NCCN) guidelines, there are systemic therapy options for HER2-amplified disease. In a phase II trial, Meric-Bernstam and colleagues reported partial responses and one complete response in patients treated with trastuzumab in combination with pertuzumab. Based upon these data, this combination therapy is included in the algorithm of patients with advanced or metastatic colorectal cancer. Therefore, the requested Enhertu (fam-trastuzumab deruxtecan-nxki) infusions are 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 Enhertu (fam-trastuzumab deruxtecan-nxki) infusions are likely to be more beneficial for treatment of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary The patient has requested authorization and coverage for the medication Otezla for his diagnosis of plaque psoriasis. The Health Plan has denied this request, indicating that the requested services were not medically necessary for treatment of the patients medical condition. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. The long-term use of traditional systemic therapies is frequently unacceptable because of renal, hepatic, pulmonary toxicity and limited efficacy. Over the past several years, the use of anti-tumor necrosis factor biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus. Despite several difficulties with documenting risks, some systemic treatments for psoriasis have been linked with an increased risk of selected cancers. In addition, patients treated with anti-TNF (Tumor Necrosis Factor) drugs may develop adverse events such as infections, acute infusion and injection reactions, autoimmunity and cardiovascular effects. It has been well-documented that therapies of psoriasis with injectable biologics increase the risk for malignancy and infection, mandating prior testing for tuberculosis. Apremilast (brand name Otezla), an oral PDE4 inhibitor, provides a novel therapeutic option for the treatment of patients with moderate to severe plaque psoriasis. Its effects on cyclic adenosine monophosphateregulated intracellular signaling, gene expression, and subsequent protein levels allow apremilast to modulate the immune responses that cause the inflammation associated with psoriasis. In this case, the patient has chronic plaque psoriasis that requires systemic treatment. The anti-TNF drugs recommended by the Health Plan can increase the risk for malignancy. Otezla is approved by the U.S. Food and Drug Administration (FDA) for treatments of such patients, and it has worked well for this patient. Final Result: The reviewer determined that the medical evidence supports Otezla in this clinical setting. Therefore, the requested medication, Otezla, is medically necessary for the treatment of the patients medical condition.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.