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

The patient is a 59-year-old female with a 12-year history of severe sero-positive, anti-CCP positive, rheumatoid arthritis who has failed treatment with prednisone, Plaquenil, Arava, sulfasalazine, methotrexate (MTX), and Kineret.  The details of these failures are not explained in the provided records (i.e. toxicity or lack of response). The patient did respond to Remicade after she was titrated to a dose of 6mg/kg every four weeks. She then had to stop Remicade in August 2004 because the cost to her was prohibitive. Without Remicade there was a worsening of her arthritis, an increased steroid requirement, repeated local steroid injections, and a reported loss of employment. The patient was restarted on Remicade at the authorized dosage of 3mg/kg every eight weeks.  This therapy again failed and her provider has requested Remicade 6mg/kg every four weeks to gain control of her disease.  The Health Plan denied the request citing a lack of medical necessity.It is well known in the rheumatology community that many patients respond adequately to Remicade only after the dosage is increased, the treatment interval is shortened, or both.  This approach is the current standard of practice in the treatment of rheumatoid arthritis. The patient has previously demonstrated a dosage response at 6mg/kg every four weeks, and therefore the medically necessary dosage and frequency has been established for this patient. A recent report in Rheumatology confirms this dosage response.  Although the requested prescription of Remicade is medically appropriate and indicated, the use of Remicade should be accompanied by MTX or another immunosuppressive agent. The submitted records indicate the patient has failed MTX but it is not known whether this was due to toxicity or lack of response. It is clear that Remicade treatment must be accompanied by MTX (or by other immunosuppressive agents such as Imuran or Arava) to avoid the appearance of haca due to the immunogenicity of Remicade itself. Based upon the information set forth above, I have determined the requested prescription is medically necessary for treatment of the patients medical condition depending upon the concurrent use of MTX or another immunosuppressive agent. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha for the treatment of her pure hypercholesterolemia.  Findings:  The physician reviewer found that this patient has evidence of early established peripheral vascular disease based on carotid ultrasound findings. She has marked increase of total cholesterol and LDL cholesterol. She has been intolerant of statin medications (atorvastatin, pravastatin and simvastatin) with development of severe myalgia.  Her LDL cholesterol remains elevated, putting her in the pharmacologic treatment range. In addition, she has a significantly elevated Apo B level, which places her at increased risk of developing ischemic disease. It is unlikely that ezetimibe alone would provide the necessary risk reduction given the inability to pair it with any statin therapy. Given this overall risk, Repatha is medically necessary for the treatment of this patient.  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 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

The enrollee is requesting authorization and coverage for facial feminization surgeries. The patient is a male-to-female transgender woman. The patient socially transitioned and has been consistently on hormone therapy for two years. She is interested in pursuing facial feminization surgery. The patients provider reports the patient has been in psychotherapy treatment with the provider. She meets the criteria for gender dysphoria. The patient currently lives as a female full-time, is confident in her gender identity, and has a social support system that is supportive of her gender, presentation, and plans for surgery. Facial feminization surgery would likely remedy her persistent gender dysphoria. Professional society guidelines support surgeries for assisting in body feminization, and can be considered medically necessary in an individual with severe gender dysphoria, depending on the unique clinical situation of a given patients condition and life situation. The medical records do not document any unique situations. The requested procedures are aesthetic procedures to make the patient more attractive in her new gender. Additionally, studies show women who had both facial feminization surgery and gender reassignment surgery did not have improved mental health outcomes compared to those who had gender reassignment surgery alone.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in plastic 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old male enrollee has requested the  prescription medication Subutex (8 mg tablets / 90 per month) for the  treatment of his back pain. Findings:  The physician reviewer found that chronic pain management is often met with significant difficulties due to its complicated and multifactorial etiology. Although Subutex has recently been approved for the treatment of opiate addiction, buprenorphine has been used for the treatment of pain for many years. The drug is a partial agonist with a high affinity for the  receptors, making it very useful in the treatment of opiate addiction. Additionally, there are several studies in which a transdermal system was used to deliver buprenorphine in the management of chronic pain. The article cited above from the American Journal of Therapeutics deals with the use of sublingual buprenorphine in patients with chronic pain that were poorly controlled with long-term opiate analgesic therapy. 86% of these patients experienced adequate analgesia without significant side effects. Subutex (buprenorphine) has been effective for this patient at the requested dosage. Given the complexities of chronic pain management, it not clinically appropriate to withdraw or significantly change a therapy that has already been shown to be successful.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee requested lumbar spine magnetic resonance imaging (MRI) with and without contrast for medical evaluation of her low back pain.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested diagnostic procedure in this patients case.  She has received epidural injections for back pain.  The patient presents with severe low back pain, and there is reference in the chart to a complete blood count showing high white blood cell count.  Given the history of injections, severe pain and high white blood cell count, there may be the possibility of epidural abscess or osteomyelitis.  As such, MRI of the lumbar spine without and with contrast would be the procedure of choice to rule out a post-procedure infectious process or hematoma which could be dangerous if left undetected.  All told, the requested lumbar spine MRI with and without contrast is medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old male enrollee has requested enhanced external counterpulsation (EECP) therapy for treatment of his angina. Findings:  Three physician reviewers found that the use of EECP in the treatment of chronic angina refractory to medical management and in patients who cannot be safely revascularized is an accepted treatment modality. However, the current ACC guidelines for the treatment of chronic angina consider EECP  an alternative therapy and make only a class IIb recommendation. A class IIb recommendation recognizes that data on the use of EECP is not clear cut and there is conflicting evidence or a divergence of opinion about the usefulness/efficacy of a procedure or treatment and that the (u)sefulness/efficacy is less well established by evidence/opinion. Given this, the current recommendations for treatment of angina are anti-anginal therapy or revascularization as first line therapies, with EECP reserved for those symptomatic patients that fail a reasonable trial of medications. The use of EECP for this patient was not consistent with the ACC recommendations.
Appeal type: Urgent Care
Decision: Upheld

A 42-year-old female enrollee has requested lactation services for treatment of her low milk supply.  Findings:  The physician reviewer found that the submitted clinical documentation fails to demonstrate that a prudent layperson would have sought immediate medical attention on the dates in question. Some of the lactation services took place prior to the birth of the patients child; thus, there was no imminent threat to the infant at that time. Following the birth, the patient presented with breast pain, poor latch, nipple confusion, and low milk supply. When patients are discharged home after delivery, some will need or desire additional lactation support and continued consultative services. There is no documentation that the patients infant was acutely clinically dehydrated, readmitted to the hospital for intravenous fluids, or was in any acute danger. While the patient was experiencing breast feeding issues and required additional lactation support services, such services were not emergent in nature. There is no evidence that the patient or her infant were experiencing significant symptomatology such that the absence of immediate medical attention could reasonably be expected to result in placing ones health in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. All told, the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old male enrollee requested Harvoni 90-400 mg x 12 weeks for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that the patient has failed sofosbuvir and simeprevir hepatitis C virus treatment. However, there is currently inadequate data to support retreatment with Harvoni especially given the absence of documented cirrhosis. The American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines state that patients who failed sofosbuvir/simeprevir should await further data supporting treatment or enroll in a clinical trial. Consistent with these findings, the requested Harvoni 90-400 mg x 12 weeks is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 59-year-old male enrollee requested the single photon emission computed tomography (SPECT) scans (CPT code 78205) for evaluation of his chronic hepatitis C genotype 1. Findings:  Two physician reviewers found that this patient has known cirrhosis due to hepatitis C virus and has undergone extensive therapy with new pharmacologic agents. The SPECT scans have allowed the treating providers to monitor the success or failure of drug agents by quantifying the uptake in the liver and spleen. Such quantification is not possible with standard planar liver spleen scans or with static imaging such as computed tomography (CT), ultrasound, or magnetic resonance imaging (MRI). All told, the SPECT scans (CPT code 78205) were likely to have been more beneficial for evaluation of this patients medical condition than any available modality.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old female enrollee requested authorization and coverage for a prescription for the medications Biaxin and Mepron.  The health plan has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees Lyme disease.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that a seven to ten day course of the requested medications is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee requested authorization and coverage of general anesthesia services. The Health Plan  denied the request indicating that the requested services are not medically necessary for the enrollees tooth extraction.One oral surgeon reviewer performed a medical necessity Independent Medical Review. The oral surgeon reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient had requested authorization and coverage for Supartz injections for the left knee. The patient has been diagnosed with osteoarthritis of the left knee. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. 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. The medical evidence supports the request services in this clinical setting. 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Avastin used in combination with Cytoxan for treatment of the enrollees recurrent ovarian cancer. Findings:  The physician reviewer found that the medical literature supports the requested medical regimen in this clinical setting. The paclitaxel/platinum combination has proven to be better than single agent platinum therapy in several clinical trials and is considered the standard for patients who relapse. Phase II studies with Avastin have shown promise in patients with platinum-refractory disease, as in this patients case. Reviewing the case file and the impressions of the oncologist, it does not appear that the original course of Avastin was aborted due to tumor progression. There were other toxicities that were due to carboplatin. Thus, the medication regimen requested is medically indicated for this patient. Moreover, there is medical evidence supporting the use of Avastin for treatment of patients diagnosed with recurrent ovarian cancer. Avastin has been successfully combined with cyclophosphamide. Therefore, Avastin used in combination with Cytoxan 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-certification in hematology and medical oncology 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 lap sleeve gastrectomy for treatment of her medical condition. Review of the submitted documentation fails to establish the medical necessity of the requested surgery. In this case, the patient previously underwent laparoscopic adjustable gastric band surgery with removal due to reflux. There is a lack of documentation provided supporting the requested surgery. There is no documentation demonstrating six months of supervised weight loss, or a multidisciplinary evaluation with psychological and dietary clearance. Moreover, there is no documentation of a technical complication of bariatric procedure that requires surgical intervention. For the reasons provided, the request for lap sleeve gastrectomy 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 general 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 Xyrem for treatment of the enrollees narcolepsy.  Findings: The physician reviewer found that the review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. Xyrem is the only U.S. Food and Drug Administration (FDA) approved medication for the treatment of narcolepsy with cataplexy. The records show a decreased mean sleep latency with two naps with REM sleep confirmed on polysomnogram that documented that the patient was not sleep deprived. Two naps with REM sleep in a patient with a reduced mean sleep latency confirms a diagnosis of narcolepsy. In addition, the patient has a history of cataplexy and severe daytime sleepiness. In this clinical setting, Xyrem has been established as medically necessary for treatment of the patients narcolepsy with cataplexy.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 pulmonary 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Euflexxa injection series to the right knee (weekly for three weeks).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 patient has a history of benefit from prior viscosupplementation. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Therefore, Euflexxa injection series to the right knee (weekly for three weeks) 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

A 22-year-old male enrollee has requested computed tomography (CT) scan of the spine, epidural injection, and Oxycontin 160mg per day for treatment of his back pain.  Findings:  The physician reviewer found that this patient had an MRI of the lumbar spine. The requested CT scan of the spine will not offer more information than an MRI particularly since the characteristics of the patients pain has not changed since the initial injury. Weiner and colleagues performed a cross-sectional study to examine the change in non-invasive/minimally invasive evaluation and treatment of nonspecific low back pain. The study also examined MRI utilization appropriateness in patients with chronic back pain. The authors concluded that low back pain documentation and diagnostic studies are increasing and evidence suggests that MRIs may often be ordered unnecessarily. With regard to the patients request for Oxycontin, the maximum recommended dose for Oxycontin is 80mg twice per day as indicated for cancer pain. This patient does not have cancer or malignant pain and he has already displayed opioid dependence and tolerance. Baron and McDonald reported that high-dose opioids might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold, and potentially masking resolution of a pre-existing pain condition. In this retrospective study, the majority of patients undergoing detoxification of high-dose opioids for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. It is therefore in this patients best interest to wean off Oxycontin and participate in adjunctive therapy such as physical therapy, massage therapy, aqua therapy or cognitive behavioral therapy, in order to address his chronic pain. All told, the medical records do not support the medical necessity of the requested CT scan of the spine, epidural injection, and Oxycontin 160mg per day for treatment of this patients medical condition.