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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for durable medical equipment (DME) RT300 functional electrical stimulation (FES) therapy system. Findings:  The physician reviewer found that records provided for review document that this patient sustained a traumatic injury to her cervical spinal cord. The patient has partial residual use of her upper limbs. She has declined to use a power wheelchair and she is using a manual wheelchair for her mobility. The mainstay of long-term management in this clinical setting focuses on surveillance and preventive clinical care related to the respiratory system, pressure injury, neurogenic bladder and bowel, tone issues, and monitoring for complications. The health and well-being in this patient population should be promoted through active exercise using volitionally intact muscles when possible and encouragement of participation in educational, social, recreational, avocational and vocational activities, i.e., at a wheelchair level. While standard rehabilitation measures may not resolve a patients neurological impairments due to their underlying spinal cord injury, the addition of an RT300 FES cycle ergometer is not expected to substantially improve health or functional outcomes beyond these standard measures. The FES cycle ergometer uses surface electrical stimulation leads to generate passive movement of the limbs to move the pedals of a stationary cycle. The intent of this passive movement of the limbs is to provide a measure of exercise and to provide various health benefits. However, the available peer-reviewed medical literature has not established that the RT300 FES provides improved health outcomes for patients with spinal cord injuries. The RT300 FES has not been shown to promote neurological recovery beyond natural recovery, or cardiovascular health, pulmonary health, bony health or other health parameters in a clinically significant manner. The FES device may help to improve or maintain muscle mass in weakened or totally paralyzed limbs, but there is a lack of data demonstrating that use of the FES provides functional benefit in this clinical setting. Given these findings, the requested DME RT300 FES therapy system is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested device 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 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 sixty-three year-old female with chronic myeloproliferative disease is requesting authorization for a trial of low-dose thalidomide.  Reviewers Findings:  The reviewing physician found that thalidomide has anti-angiogenic and immunomodulatory properties; a review of the medical literature revealed many articles and abstracts in support of using low-dose thalidomide in this clinical scenario.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Physician 1: The patient is a 60-year-old woman with chronic daily headaches and underlying migraine. She has failed Inderal, Topamax, Depakote, Zanaflex, nortriptyline, Neurontin and Keppra. She responds to triptans. The patient was tried on Botox three times with very good results. The Health Plan has denied coverage for Botox indicating it is experimental.The patient has chronic daily headaches most consistent with chronic migraine as documented by the patients diary and treating neurologists notes. The patient has tried and failed over eight preventive therapies. The submitted notes demonstrate the patient had significant improvement in her headaches with prior use of Botox. Therefore, I have determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2: The patient is a 60-year-old female with chronic migraine refractory to multiple abortive/prophylactic medications as noted in the submitted records. She has responded to trials of Botox injections and wishes to continue treatment with Botox. The Health Plan indicates the efficacy of Botox has not been established in peer-reviewed literature.The submitted information indicates the patient tried a number of medications, which apparently were ineffective. Review of the neurological literature reveals the use of Botox for headache is common and widespread in the practice of neurology as it is very effective and well tolerated. Furthermore, there is evidence the patient has benefited clinically from Botox. Therefore, I have determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3: The patient is a 60-year-old female who has a history of migraines, now with chronic daily headaches. Several preventive medications have been tried without success including nortriptyline, Bellamine, Neurontin, Topamax, and Keppra. She has since been treated with Botox and is reported to have had improvement in her headache pain. The Health Plan has denied coverage for Botox on the basis it is considered investigational for treatment of migraines.This patient has refractory migraines. She has tried and failed more than three preventive regimens and needs abortive treatment with triptans. Excessive acute medication overuse can lead to rebound headaches. Review of the scientific literature demonstrates evidence exists that Botox can be beneficial for treatment of chronic daily headache and refractory migraines. Additionally, the patient has benefited from Botox. The likelihood of similar benefit with further trials of more preventive medications is low. Therefore, I have determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for placement of SpaceOAR hydrogel. The records provided for review demonstrate that this patient presented to his provider with an elevated prostate specific antigen (PSA). Biopsy revealed Gleason score 3+4 prostate cancer. His provider recommended SpaceOAR hydrogel placement for use with radiation therapy. The use of the SpaceOAR hydrogel was within standard of care in this patients clinical setting. Recent data has demonstrated that the incorporation of SpaceOAR hydrogel yields superior clinical outcomes as compared with definitive radiotherapy without the use of SpaceOAR hydrogel. SpaceOAR was shown in a phase III randomized prospective setting to minimize the risk for radiation-induced urinary and bowel side effects. Moreover, the use of SpaceOAR hydrogel is supported by the National Comprehensive Cancer Network (NCCN) for patients with prostate cancer undergoing radiation therapy. For these reasons, placement of SpaceOAR hydrogel was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the placement of SpaceOAR hydrogel was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage of Epclusa. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America (AASLD/IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions.  Per the guidelines, patients with cirrhosis are high priority for treatment, and should be re-treated after failure of an NS5A inhibitor such as Harvoni.  After failure of an NS5A inhibitor, AASLD/IDSA guidelines recommend re-treatment with Epclusa and ribavirin for 24 weeks. The guidelines state that retreatment with sofosbuvir/velpatasvir plus ribavirin for 24 weeks should be considered in genotype 1 patients who have not responded to prior NS5A-based therapy. 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: Overturned

A 54-year-old male enrollee requested authorization and coverage for Viagra. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees erectile dysfunction.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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for lumbar spine magnetic resonance imaging. The enrollee has a history of back pain. A spinal x-ray showed multilevel spondylolisthesis of L3, disc narrowing/degeneration, and facet spondylosis. A progress note showed the physician ordered piroxicam, 10 milligrams, once a day for 30 days, naproxen, 375 milligrams, every twelve hours for 30 days, and he placed an order for a lumbar spine magnetic resonance imaging scan. The enrollee reports that she has experienced severe medical complication with the lower back lumbar area, which has caused further complications, such as uncontrollable bowel movements. The enrollee reports she has visited chiropractors and used other alternative means of treatment to relieve her pain. This enrollee has experienced back pain for almost a year. Despite home exercise, activity modification, and the use of non-steroidal anti-inflammatory medications, including naproxen and piroxicam, she has experienced severe pain in the back and left knee, and more recently in the right foot. Given the persistent symptoms of pain and radiculopathy, and the abnormality seen on the x-ray, the lumbar spine magnetic resonance imaging scan is medically necessary for the enrollee's medical condition.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in neurosurgery 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyperbaric oxygen treatment for treatment of the enrollees hearing loss.  Findings:  The physician reviewer found that superior efficacy of this treatment modality lacks support in current medical literature. There is a lack of strong data to show that hyperbaric oxygen therapy is beneficial for treating sudden hearing loss. The use of hyperbaric oxygen therapy for Menieres disease remains of unproven benefit and is not likely to be more effective than the standard methods of treating sudden hearing loss. In addition, upon review of the most recent audiograms, they indicate the patient had very mild loss/normal hearing. In sum, hyperbaric oxygen treatment is not likely to be more efficacious than the available therapy for treating this patients medical condition.Final Result: All three reviewers have determined that the requested services are not likely to be more beneficial for treatment of your medical condition than any available standard therapy.Credentials/Qualifications:  All three reviewers are board certified in otolaryngology 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: Overturned

The patient is a 48-year-old male with degenerative changes, curve alteration, and persisting pain of the neck. Symptoms extending to the upper extremities are now relieved, but neck pain persists. The patient has a history of extensive examination and medical treatment including plain x-rays and MRI, treatment by epidural injections times three, medications, and chiropractic care. Six chiropractic treatments have been authorized. The patients extremity complaints have been relieved and his neck pain has eased with chiropractic treatment. The patients primary care physician has written a letter of support for the chiropractic treatment. The patients treating chiropractor has stated complicating factors are present; as such, he has recommended 14 more treatments over a period of two months. Authorization and coverage for the additional care has been denied by the Health Plan on the basis it is not medically necessary for treatment of the patients neck and shoulder pain.This patient has had extensive diagnostic and medical treatments. The record reveals complications of degenerative joint and disc disease with disc extrusion at C7-T1 supported objectively with MRI and plain x-ray studies. Chiropractic care is supported by the patients primary care physician and has helped this patient by diminishing his pain and allowing him to decrease his use of pain medication. The Health Plan has not offered a specific alternative service to chiropractic care and the disputed care is as or more clinically appropriate than the treatments received before chiropractic care. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. Additional chiropractic treatment should be authorized at least twice a week for three weeks with a decrease to once per week for three weeks concurrent to a developed and practiced home program for self-reliance. Exacerbations may dictate treatment beyond this recommendation, but should not be an intensive as the initial course of care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment level of care. Findings:  The physician reviewer found that due to the lengthy history of drinking and increased reports of consumption, a residentially-based detoxification and preliminary introduction to chemical dependency treatment was safe, appropriate and consistent with good medical practice.  However, although addiction specialty services remained indicated, the clinical documentation does not demonstrate the medical necessity of treatment in a 24-hour supervised setting.  First, the absence of significant comorbidity supported a less restrictive setting.  The patient completed detoxification, and there was no evidence of the emergence of late alcohol withdrawal symptomatologies.  Despite the diagnosis of hypothyroidism and hypertension, the patient was medically stable.  Although she had dependent personality traits and mild depressive symptoms, the patient did not have a degree of psychiatric impairment that would necessitate a residential treatment setting.  Second, the patient embraced recovery principles and was motivated in her quest for sobriety.  She had no other addictions besides alcohol.  Aside from the failed outpatient program and a few Alcoholics Anonymous meetings, the patient had no prior history of chemical dependency treatment in a less restrictive setting, such as anti-craving medication, community programming, intensive outpatient services or partial hospitalization.  This is significant in this case for two reasons.  First, modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment.  Second, there was no evidence to suggest that comprehensive, evidence-based services provided a less restrictive treatment setting would have been insufficient or inadequate at the time.  All told, residential treatment level of care provided was not medically indicated for the treatment of this patient. Final Result: The reviewers determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 35-year-old female enrollee requested authorization and coverage of a referral to a plastic surgeon for a possible panniculectomy. The Health Plan has denied this request indicating that a panniculectomy is considered cosmetic in nature and not medically necessary for treatment of the enrollees excess abdominal tissue.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial of the referral on the basis that the requested referral is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for fertility preservation services. With current technology, sperm and embryo, as well as oocyte cryopreservation, are considered standard practice and are widely available. Such treatment is considered the standard of care by the American Society of Clinical Oncology and the American Society for Reproductive Medicine and has been shown to be successful. In this case, the patient's fertility status after breast cancer treatment with chemotherapy is uncertain. Therefore, in order to preserve this patients fertility, it was medically necessary for the patient to undergo fertility sparing treatments. Accordingly, the fertility preservation services at issue (ovarian stimulation, oocyte retrieval, oocyte fertilization and storage of oocytes and/or embryos) were medically necessary because of the treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary because of the 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: Experimental/Investigational
Decision: Upheld

A 51-year-old male enrollee requested authorization and coverage of intradiscal electrothermal therapy (IDET). The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees back pain. Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha SureClick 140 mg/mL for treatment of the enrollees hyperlipidemia.Findings:  The physician reviewer found that the records document hyperlipidemia.  However, the medical record documentation does not support known coronary disease or findings of homozygous familial hyperlipidemia.  This diagnosis requires not only elevated low-density lipoprotein levels which significantly exceed 180 mg/dL, but also a combination of physical examination findings (arcus cornealis below the age of 45, tendon xanthomata), a strong family history of coronary disease (younger than 50 years in second-degree relative or aged younger than 55-60 years in first-degree relatives) and documented genetic defects related to cholesterol metabolism according to published criteria.  Repatha is a PCSK9 inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of low-density lipoprotein cholesterol.  The medical record documentation does not support that this patient meets either of those criteria.  PCSK9 inhibitors have not been studied in other patient populations such as this patient.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The 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.