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

Nature of Statutory Criteria/ Case Summary: At issue is whether Norco is medically necessary to treat the patients medical condition. This is a patient that experiences chronic pain and arthritis in the back, hips and knees, fibromyalgia, gout, and severe kidney disease. The patient has been evaluated by orthopedics, physical medicine, and pain management. The patient takes Norco pain medication three times a day for pain relief. The last Norco refill is dated 12/13/19 for 90 tablets. The patient requested a Norco refill on 1/7/20. The provider requested a urine drug test. The urine drug test was positive for tetrahydrocannabinol (THC, the active ingredient in marijuana), opiates (contained in the Norco) and hydrocodone (contained in the Norco). The provider requested the patient to come in for an in-person discussion of the urine test results, a referral to pain management and an opioid medication agreement. The patient has declined to come in for the in-person visit and discussion with the provider. The researchers recommend that until scientific evidence is forthcoming, that opioid prescribers do not support patients concomitant use of marijuana, be it medically certified or illicit, and they should make continued opioid receipt contingent on marijuana use cessation. The submitted documentation shows the patient had THC in the urine drug test of 2/20 and that the patient signed an opioid agreement in 2018. The treating provider in this case has requested the patient come in to the office for an in-person discussion of the patients urine test results, the opioid medication agreement, and a referral, before any further opioid medication can be prescribed. This is a reasonable, prudent, and appropriate approach to the patients medical care and safety with the use of an opioid and THC. The submitted documentation shows that this patient has chosen to decline attending the requested in-person discussion with the provider. Therefore, Norco is not medically necessary to treat this patients condition.   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 anesthesiology and pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a stress echocardiogram for evaluation of the enrollees medical condition. Findings:  The physician reviewer found that this patient presented with coronary risk but no documented chest discomfort, a normal cardiovascular physical examination and a normal electrocardiogram.  The letter from the provider is not consistent with the medical records provided.  In the absence of documented chest discomfort, cardiac physical examination abnormalities or electrocardiographic abnormalities in the medical records, the medical necessity of the services at issue cannot be established.  Current guidelines that are endorsed by several national organizations do not consider stress echocardiography appropriate in the absence of documented chest discomfort or other findings concerning for coronary ischemia in the medical records.  Screening stress testing, even in patients with increased coronary risk, has not been demonstrated to improve cardiac outcomes.  Final Result: The reviewer determined that the services at issue were 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier for 12 weeks for treatment of the enrollee's hepatitis C virus.  Findings: The physician reviewer found that according to the 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. The guidelines recommend treatment based on prior therapy. The guidelines state that non-cirrhotic genotype 1a patients who have failed peg-interferon and ribavirin should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on the C-EDGE TE clinical trial results showing a 94% cure rate when NS5A resistance is absent (Kwo, et al).  Although the patient may have failed a different regimen three to four years ago, failure of such a regimen would not be relevant to the efficacy of Zepatier, a combined NS5A and NS3/4 inhibitor, when NS5A resistance testing is negative. Moreover, the AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, treatment with Zepatier for 12 weeks is 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: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee has requested a metabolic brain positron emission tomography (PET)/computed tomography (CT) scan for evaluation of her language and cognition difficulties. Findings:  Two physician reviewers found that the available peer reviewed medical literature provides a review of the use and limitations of PET/CT scan, including its use to differentiate frontotemporal dementia and Alzheimers disease, as well as its use and limitations for the initial evaluation of dementia. The scientific data does not demonstrate PET/CT scans are a substitute for detailed clinical evaluation, simple laboratory tests and basic structural imaging (Visvanathan). PET/CT imaging as a primary diagnostic tool for early cognitive symptoms has not been proven to be beneficial or effective for patients and is not currently considered the standard of care. In addition, it is unlikely that such a study would substantially change management in a case such as the one documented through this record. Although a PET scan is useful in some instances, such as differentiating between Alzheimers and frontotemporal dementia, or in some cases of malignancy, there is no documentation in this case that is suggestive of these indications.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for Anser IFX Prometheus Lab testing for evaluation of the enrollees Crohns disease.  Findings: Two physician reviewers found that the Prometheus Anser IFX test is a quantitative measurement of serum infliximab (IFX) and anti-IFX antibodies. Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear. Some evidence exists that low serum levels of infliximab or the presence of IFX antibodies have an adverse effect on the clinical outcome of a patients response to treatment. However, although there have been testimonials, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Nanda, et al). In addition, it has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. While it can be argued in this patients case that detection of antibodies to infliximab would have contraindicated its restart, there was no indication for measuring serum levels of infliximab in this patient who had stopped the medication six months earlier. Thus, the Anser IFX Prometheus Lab testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the upper and lower extremities. The submitted documentation fails to support the medical necessity of the requested services. The only reason to obtain any imaging study is if it will change the medical management. In this case, the requested services are not likely to change medical management. There is no indication that the patient is being assessed for surgery. Even if the patient has a rotator cuff tear, the immediate management will still be rest, intensive physical therapy and nonsteroidal anti-inflammatory medications. Additionally, the submitted records do not support MRI for evaluation of the patients reported ankle pain. The medical evidence does not support the requested services in this clinical setting. Therefore, the requested MRI of the upper and lower extremities is not medically necessary 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for consultation for suction-assisted lipectomy surgery for evaluation of the enrollee who has a history of lymphedema. Findings:  The physician reviewer found that there is support in the medical literature for the requested services in this clinical setting. The submitted records indicate a progressive left lower extremity lymphedema following a previous left inguinal node biopsy. She is well-documented to have suffered complication with cellulitis/sepsis related to her condition. She has undergone typical conservative management, including compression garments, physical therapy, pumps and elevation. This has failed to control or treat her condition.  Liposuction is a well-known therapy for lipodystrophy and has been shown to provide possible functional improvement in lymphedema. As recommended in the medical literature, surgical treatment is reserved for these types of patients. The documentation provided has indicated that current standard of care management has failed in this patient. Her condition has been documented to have affected her function with significant infection/sepsis. The patient has significant functional compromise related to her progressive lymphedema that has failed reasonable conservative measures. Thus, it is medically appropriate to consider other forms of treatment when non-operative measures have failed. There is enough evidence in this patients case to suggest surgical intervention and lymphatic liposuction is one of them. As such, it would be reasonable for this patient to seek consultation prior to determining surgical options. Thus, a consultation for suction-assisted lipectomy surgery is medically necessary for 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 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laser assisted uvula palatoplasty surgery. Findings: The physician reviewer found that the medical evidence does not support the requested services in this patients case. The records document mild obstructive sleep apnea. He has failed a couple of treatment modalities. The requested procedure, laser assisted uvula palatoplasty, has largely fallen out of favor due to its ineffectiveness in treating obstructive sleep apnea. This procedure was popular in the 1990s and early 2000s, but when long-term results showed poor improvement in snoring, it became unpopular for treating snoring as well. At this point, the laser assisted uvula palatoplasty surgery would not be indicated in treating this patients obstructive sleep apnea. The uvulopalatopharyngoplasty would be more beneficial for this patients condition than the requested services.  All told, the requested laser assisted uvula palatoplasty surgery is not medically necessary for the treatment of this patient. Final Result: The reviewers determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number is board certified in otolaryngology 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 sixty-two year-old obese male with asthma, degenerative disc disease, diabetes, Guillain-Barre syndrome and recent fractures involving his foot and great toe is requesting authorization for continued use of the bariatric bed.   Reviewers Findings:The reviewing physician found that the patient does not meet medical necessity requirements for a bariatric bed.   The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400-100 mg for 12 weeks for treatment of the enrollees hepatitis C.Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1a patients should be treated with Epclusa for 12 weeks. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. All told, Epclusa 400-100 mg for 12 weeks 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-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: Experimental/Investigational
Decision: Overturned

A 49-year-old female enrollee requested authorization and coverage of gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One  physician reviewer concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested surgery is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old female enrollee has requested a magnetic resonance imaging (MRI) neurography scan of the upper extremity, for evaluation of her cervical and upper extremity pain. Findings:  The physician reviewer found that MRI neurography has been shown to provide evidence of injury to peripheral nerves in animal studies. In cases of brachial plexus neuritis, there are changes seen in the images which may be helpful in evaluation. In some cases, it has been of value in the visualization of brachial plexus abnormalities from a variety of causes, and the feasibility of the technique has been demonstrated. However, the amount of additional diagnostic information obtained from this technique, as compared to other studies such as EMG, is limited, and it remains a complementary study to clinical examination and electrodiagnostic studies.In this patients case, there was a lack of documentation of the indications for this procedure, with no discussion of correlation of other studies with clinical findings to point to the brachial plexus as the source of her problem. As such, the medical necessity of the MRI neurography has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 45-year-old female who has degenerative disc disease and low back pain.  An MRI revealed an annular tear at L5-S1. She is requesting authorization and coverage for artificial disc replacement surgery at this level. The Health Plan has denied the patients request because it considers this procedure experimental.The Health Plan is correct that the proposed procedure is considered experimental. The artificial disc is currently being investigated for single level disc replacement in the treatment of degenerative disc disease in the lumbar spine. Current data for single level disc replacement demonstrates a 63% short-term success rate; however, long-term outcomes are unknown and complications may be severe. Because there is insufficient evidence supporting the safety and efficacy of artificial disc replacement, I have determined the requested procedure is 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.Physician 2: The patient is a 45-year-old female with chronic progressive low back pain secondary to internal disc disruption syndrome at L5-S1. Her physician has recommended artificial disc replacement surgery. The Health Plan indicates the efficacy of artificial disc replacement has not been established.The current clinical evidence regarding the Charite III disc has allowed for Food and Drug Administration (FDA) approval that it is not inferior compared to fusion. Similarly, current studies appear to indicate it is not worse than fusion. Additional claims of efficacy are based upon a small number of short-term, non-randomized studies. A 300-patient FDA regulated investigational device exemption trial with long-term follow-up is underway. Without the results of this trial, the Charite III disc replacement remains experimental. Furthermore, it is not established as superior to fusion. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 45-year-old woman who has degenerative disc disease at L5-S1. She has failed conservative treatment options. The patients provider has recommended a single level artificial disc replacement procedure. The Health Plan has denied authorization for the requested procedure citing a lack of proven efficacy.The proposed procedure is experimental without established long-term safety and efficacy. Available data does not demonstrate an advantage to disc replacement over fusion. The long-term safety profile is unknown. There is no clinical indication demonstrating the proposed procedure is the best treatment option for this patient. There are other treatments available. For these reasons, I have determined the requested procedure is 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.