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

A 47-year-old male enrollee requested authorization and coverage of the medication viagra for the treatment of erectile dysfunction.  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 overturned the health plans denial on the basis that the requested medication is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 45-year-old male enrollee has requested Gleevec for treatment of his desmoid tumor.  Findings:  Three physician reviewers found that Desmoid tumor (aggressive fibromatosis) can be a recurrent, though not metastatic, form of neoplasia. Standard chemotherapy has rarely been of much value. Gleevec, which is approved for use in chronic myelogenous leukemia and gastrointestinal stromal tumors, has indeed been reported to have some efficacy in desmoid tumors. There are multiple papers documenting this as cited above. Because of the rarity of desmoid tumor, Gleevec will probably never be approved for treatment of this condition. However, there is enough data to believe it is more likely to be effective than any of the more conventional forms of chemotherapy than might be offered.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested anesthesia services for treatment of the enrollee, who underwent a colonoscopy.  Findings: The physician reviewer found that there is sufficient support for the services at issue in this clinical setting.  This patient has Class I obesity.  Judgment of the need for monitored anesthesia care requires consideration of procedure requirements and potential risks.  Patients with Class I obesity have been found to be at significantly higher risk for desaturation during endoscopic procedures.  Wani and colleagues noted a higher risk for sedation-related complications with a body mass index greater than 30 during endoscopic procedures.  Based on the current medical literature, this patient was at increased risk for sedation-related complications.  All told, anesthesia services are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue 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 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: Overturned

An 18-year-old female enrollee has requested partial hospitalization program (PHP) level of care services for treatment of her bulimia nervosa.  Findings:  The physician reviewer found that based on review of the available records, this patient has continued to struggle with omissions and restrictions of her insulin. She also continued to binge and restrict. The patient reported that she has binged every night since the said date, which is important because she was in PHP level of care, and was not supervised at night. This indicates that she was still in need of a considerable amount of supervision to stay safe. According to the American Psychiatric Association (APA) level of care guidelines for eating disorders, PHP is indicated when the patient has partial motivation and still needs some structure beyond self-control to prevent purging and compulsive exercising. This patient has the additional burden of diabetes mellitus I and misuse of her insulin, adding further complications to her health. For these reasons, the patient met the APA guidelines for PHP services provided during the said time frame. Therefore, the PHP services at issue were medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Repatha for treatment of his medical condition.  The physician reviewer found that the patients medical records do not document absolute contraindication to the currently prescribed lipid medications, or absolute intolerance to the currently prescribed lipid medications, and given that the patient has experienced effective lipid lowering to a goal on current medications, a PCSK9 inhibitor such as Repatha is not medically necessary at this time. Medical studies support the use of PCSK9 inhibitors for patients who are unable to take statin medications and/or need additional reduction in LDL cholesterol; the patients records do not document either in this case. For these reasons, the requested medication is not medically necessary for treatment of the patients coronary disease. 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: Experimental/Investigational
Decision: Upheld

A 74-year-old male enrollee has requested coverage for X-STOP implantation surgery for treatment of his lumbar stenosis. Findings:  Two physician reviewers found that the X-STOP device is designed to distract the posterior elements of the stenotic segment of the spine and place it in flexion to treat neurogenic claudication. These devices continue to be evaluated in clinical trials. Early results suggest a possible role in the management of degenerative disorders of the lumbar spine. In the study evaluating the device, the primary indications were age of at least 50 years, lower extremity pain (with or without back pain) that was relieved with flexion and the ability to walk at least 50 feet. However, the FDA documents were released before a public hearing on the product raised concerns that the X-STOPs effectiveness decreases over time. Studies found that about 15% of patients who had the implant reported symptoms returning. It appears that the X-STOP is only effective for about a year and then efficacy begins to decline, according to the FDA. Additionally, this patient has multi-level disease at L3-4, L4-5 and L5-S1 that would be a relative contraindication to the use of the X-STOP device.
Appeal type: Experimental/Investigational
Decision: Upheld

A 29-year-old male enrollee has requested immune cell function assay (CPT code 86352) for treatment of his status post open heart surgery. Findings:  Two physician reviewers found that the immune cell function assay testing performed was not likely to be more effective for this patient than other available options. Although the International Society of Heart and Lung Transplantation give a Class IIa recommendation for acute cellular rejection screening using gene expression profiling (AlloMap testing), there is a lack of consensus at this time on the use or value of immune cell function assay testing using a functional T cell assay. In order to assess the value of functional T cell assays in heart transplantation, future prospective studies are needed. Therefore, the services at issue were not likely to be more beneficial than any standard treatments for this patient medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a l5-year-old male enrollee has requested prescription medication Lexapro for treatment of depression.  Findings:  The physician reviewer found that the pharmacy information concerning Celexa (citalopram) and Lexapro (escitalopram) suggests a similar pharmacological action with similar side effects. Both medications are SSRIs. Lexapro is the newer of the two drugs, and the Health Plan requires a trial of Celexa prior to authorization of Lexapro. A requirement such as this is not uncommon with a restricted formulary. Given that Lexapro was effective for this patient, it is very likely that Celexa will also be effective as the two medications are almost identical in their action and side effect profile. Lexapro is made from a different molecule than Celexa, but the switch from Lexapro to Celexa, adjusted for a difference in potency, should offer the same clinical benefit for the patient.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee has requested the prescription medication Actiq (1200 mcg x 210 lozenges for the treatment of his pain. Findings:  The physician reviewer found that Actiq is currently FDA approved only for opioid resistant breakthrough cancer pain syndromes.  This is because of a significant and potentially fatal side effect profile, which includes addiction and respiratory depression. Actiq has not been studied for this patients clinical pain syndrome.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Two physician reviewers found that tomosynthesis provides advantages to radiologists in the interpretation of digital mammography. Tomosynthesis has the ability to separate architectural distortion from underlying malignancy/mass. This advantage is important in this particular case in light of the post lumpectomy architectural distortion in the left breast. Post lumpectomy architectural distortion may be difficult to differentiate from the distortion associated with malignancy/recurrence.  This was likely more possible with the addition of tomosynthesis than had the exam been done with two-dimensional imaging only.  Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

This is a five-year-old girl with cerebral palsy who is dependent for activities of daily living and mobility. She is unable to roll over. She is microcephalic and has limited hip abduction. There is no demonstrated purposeful movement and low potential for mobility. She was provided with a gait trainer issued in February 2003.The patient has a gait trainer already that appears to be adequate. There is no evidence that the patient will benefit from the use of any gait trainer. There is no evidence that the requested gait trainer is medically necessary. The Health Plan is offering an appropriate alternative in the form of a physical therapy evaluation to determine the patient's equipment needs. Therefore, I have determined that the requested equipment is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 13-year-old female with a relative idiopathic short stature with somewhat low levels of IGF-1, but a normal growth hormone (GH) response to provocative testing. She has advanced normally into puberty and since April 2004 has been given Lupron in an attempt to delay puberty as well as therapeutic GH. A positive growth response by October 2004 was observed. The patients pediatric endocrinologist contends that a neurosecretory GH deficiency may be present. The patients height potential should be 56-57 as judged from the mid-parental heights, but her predicted height from a recent bone age was near 51.  Based upon the notes provided, the patient was growing above the 10th percentile for height and had gained some 13 pounds in weight prior to beginning hormonal therapies. From September 2003 to March 2004 the patient grew at a rate of 6.4cm/year. During six months of GH therapy (April 2004  October 2004) the patient grew at a rate of 7.6cm/year and gained another five pounds.A request has been made for authorization and coverage for GH therapy. The Health Plan has denied the request on the basis that the requested therapy is not medically necessary.Whereas it appears clear the patient is likely to be shorter than her mid-parental height would otherwise suggest, she had been growing above the 10th percentile without GH therapy. Furthermore, she is taking Lupron to delay the advancement of her puberty and thereby hoping to extend her growth period. It remains problematic to what extent therapeutic GH would increase her final height if continued. The growth response data over the early months of GH therapy are not impressive. In light of these results, I have determined further use of GH therapy is not medically warranted. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 32-year-old female enrollee has requested for cervical artificial disc replacement for treatment of her degenerative disc disease. Findings:  Three physician reviewers found that the peer reviewed literature to date fails to establish with any certainty that the artificial disc is more effective than standard methods of treatment. Disc implants have not become the standard of care nationwide. Although they are approved for use at this time, the FDA has also determined that further study is needed. The long-term viability of these disc implants is not known. Their superiority to more traditional surgical techniques has not been conclusively established. In this specific case, the use of the artificial disc has been recommended at the two junctional levels (C4-5 and C6-7) with fusion of the middle segment (C5-6). This type of surgery has had even less study and is outside of the FDA approved indications for the use of the Prestige disc.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old female enrollee, diagnosed with osteoarthritis of both knees, has requested authorization for repeat Hyalgan injections. Findings:  The physician reviewer found that patients who are treated with this type of injection often find the therapy becomes less effective after six to twelve months at which time it is medically reasonable to repeat the injections.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Positron Emission Tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh. Findings:  The physician reviewer found that The most accurate assessments of disease activity typically occur when previously abnormal studies are repeated on a serial and regular basis. Generally, the same method of assessment should be used over time. In patients with metastatic breast cancer, tumor response on PET/CT appears to be a superior predictor of progression-free survival and disease-specific survival than response on CT. In this case, the patient has had PET scans to monitor her disease with metastases limited to the bones. Records indicate that prior to the scan at issue, her last scan was over a year prior. Therefore, the PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; skull base to mid-thigh provided on 3/18/21 was medically necessary for the evaluation of the patients medical condition.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 internal medicine with sub-specialty certification in 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for electrostimulation biofeedback physiotherapy (a total of six one-hour sessions). Electrostimulation biofeedback physiotherapy is a pelvic floor rehabilitation technique that is well supported in current medical literature for the treatment of urinary/fecal incontinence, pelvic pain, erectile dysfunction, defecatory disorders, and dyssynergic defecation. These techniques are largely designed to increase the internal urethral and rectal sphincter tone to avoid incontinence. Researchers report that biofeedback is an effective therapy for defecatory disorders and for constipation with dyssynergic defecation. The authors note that biofeedback therapy is a mainstay of management of common anorectal disorders, including fecal incontinence, functional anorectal pain, and functional defecation disorders. In this case, the records note that the patient has constipation as a result of the increased sphincter tone and a diagnosis of pelvic floor dyssynergia. The patient reports an inability to engage in rectal sexual activity due to his condition. In this clinical setting, the requested services are medically indicated. Therefore, electrostimulation biofeedback physiotherapy (a total of six one-hour sessions) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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

A female enrollee requested Sovaldi for medical treatment of her hepatitis C virus.  Findings:  Two physician reviewers found that the medical records demonstrate low-stage fibrosis, however her fibrosis score does not diminish the medical necessity of her genotype 2 treatment. Sovaldi and ribavirin, is the only treatment option available to her and this regimen is medically necessary to prevent worsening of HCV condition such as liver malfunction. As such, Sovaldi is medically necessary to treat of the patients HCV genotype 2.
Appeal type: Medical Necessity
Decision: Overturned

A 20-year-old male enrollee has requested a knee brace for the treatment of his knee following right anterior cruciate ligament (ACL) reconstruction. Findings:  The physician reviewer found that the patient has undergone multiple surgeries on his right knee and even though some repairs have been done, this is an on-going risk of instability in the knee due to the deficiency of the ACL and meniscus. As such, he is likely to be at risk of right knee instability on a long-term basis, especially during high demand activities such as running, jumping or stair climbing. A correct fitting right knee stabilization brace was medically indicated for this patient and the need is likely to continue.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni for eight weeks. Findings:  The physician reviewer found that according to 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 applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per the guidelines, treatment naive genotype 1 patients should be treated with Harvoni. Patients with viral loads less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni for eight weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Otezla starter pack (day 1 to day 5) followed by Otezla 30 mg twice daily starting on day 6. Otezla is a small molecule drug that inhibits phosphodiesterase-4 (PDE-4). This action decreases the levels of proinflammatory cytokines like tumor necrosis factor alpha (TNF-a) and interleukin (IL)-23 and increase anti-inflammatory mediators. This decreases anti-inflammatory action in many inflammatory diseases like psoriasis and dermatitis. As this patient has already failed many traditional therapies for psoriasis, Otezla is the next logical treatment step. Otezla is a safe and efficacious treatment that is U.S. Food and Drug Administration (FDA) approved for psoriasis and shows great efficacy in the treatment of dermatitis (Mobasher, et al.; Papp, et al.). Given this support, Otezla starter pack (day 1 to day 5) followed by Otezla 30 mg twice daily starting on day 6 is medically necessary for 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 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.