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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco and Diazepam for treatment of the enrollees chronic low back pain. Findings: The physician reviewer has found that based on the documentation submitted for review, the patient has had long-term opioid use and has been prescribed benzodiazepines medication on a long-term basis. He describes symptoms of withdrawal from both medications when unavailable. These medications have been prescribed as part of his care. Guidelines for opioid and benzodiazepine dependence recommend a slow taper when these medications are discontinued. In terms of Norco, a suggested taper is 10% every two to four weeks. In general, weaning of benzodiazepines such as diazepam takes more time than opioid withdrawal. Although there is no currently universal weaning protocol available, one current recommendation of tapering is about 1/8 to 1/10 of the daily dose every one to two weeks. An alternative weaning schedule is to decrease by 10% a week or 5 mg (whichever is smaller). The first 50% of weaning is generally smoother than the last 50%. When the final 25% to 35% of dose is reached it is suggested that the decrease in dose be lowered to 5% at a two-week interval. The rate of withdrawal should be individually tapered based on signs and symptoms and visits should occur on a weekly basis during weaning or more often if clinically indicated. Discontinuing either Norco or Valium without an appropriate plan for tapering risks withdrawal symptoms. For the reasons provided above, the request for Norco and diazepam is medically necessary until an appropriate plan for tapering is devised and implemented. Final Result: The reviewers determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 51-year-old woman with a diagnosis of Crohns disease who is suffering from frequent diarrhea.  She has been treated with several different medications, but they did not remedy her symptoms. The patient has been using Sandostatin for the past three years and believes that it decreases the frequency of her diarrhea.  She is requesting that the Health Plan authorize continued usage of the medication. The Health Plan has denied her request based upon their determination the Sandostatin is not medically necessary for the treatment of Crohns disease.The submitted records do not include much detail as to the character of the patients diarrhea. The FDA however, has not approved Sandostatin for the treatment of diarrhea related to Crohns disease, nor is it indicated according to the community standard of care. As such, based on the clinical information provided, the use of Sandostatin is not medically warranted in this case. Accordingly, I have determined the requested medication 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 61-year-old female enrollee has requested Orthovisc injections for the treatment of her knee pain. Findings:  Two physician reviewers found that the use of Orthovisc is not experimental for treatment of osteoarthritis of the knee. However, documentation that a full course of conservative treatment for patellofemoral arthritis has been tried and failed is lacking. The documentation does not support an adequate course of NSAIDs, physical therapy, or cortisone injections, as discussed in the reference by Zhang and colleagues. Before the use of viscosupplementation is appropriate, a trial of conservative measures must be documented.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xeljanz tablets. The patient carries a diagnosis of seronegative rheumatoid arthritis. However, she also has dip involvement and there is a question of some other inflammatory arthritis or erosive osteoarthritis. The patient has failed or not tolerated multiple disease modifying anti-rheumatic drugs (DMARDS). The patient has been treated with biologic therapies, including Enbrel, Humira and Simponi. The American College of Rheumatology (ACR) recommends the use of anti-tumor necrosis factor (TNF) agents after the failure of DMARDS, or combination DMARDS with or without low dose steroids (Singh, et al.). The requested therapy is not superior to the Health Plans formulary anti-TNF therapies in terms of efficacy or safety. Additionally, all biologics require that the patient be tested for latent tuberculosis and hepatitis B and C, which has not been documented in this case. Finally, there is no documentation that the patient has an absolute neutrophil count (ANC) greater than 1000 cells per mm3, lymphocyte count greater than 500 cells per mm3, and a hemoglobin greater than 9 grams per dL. Therefore, Xeljanz tablets is not medically necessary for the treatment of this patients medical condition. 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 subspecialty certification in rheumatology 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 39-year-old male enrollee has requested electroconvulsive therapy (ECT for treatment of his depression. Findings:  The physician reviewer found that there are many unanswered questions regarding the interplay between the patients depression and his borderline personality disorder. Questions have also been raised about the efficacy of psychotropic medications versus the possibility of noncompliance. Regardless of these concerns, the primary consideration in determining the need for ECT is the extent of the patients depression at the point of admission. The clinical record indicates the patient was severely depressed with a full array of neurovegetative symptoms. Despite the unanswered questions, there is no question as to the validity of the patients depression. ECT is an appropriate course of treatment for severe depression and failed pharmacotherapy is not a prerequisite to prescribing ECT.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ injections for treatment of the enrollees short stature. Findings:  The physician reviewer found that The patients height and weight decelerated simultaneously, a pattern that is not consistent with growth hormone deficiency and is more likely to be related to decreased caloric intake and/or constitutional delay. The patients height is not greater than two standard deviations below the mean for age and gender. His bone age is not delayed, and IGF-1 level is not low. The provider noted a predicted adult height of 54. However, based on the patients bone age and height measurement, the estimated final adult height is approximately 68 inches using the Bayley-Pinneau method. This is a normal adult height that is appropriate for the genetic potential and not consistent with growth hormone deficiency. Growth hormone stimulation testing has poor specificity for the diagnosis of growth hormone deficiency, particularly in an unprimed child who is pre-pubertal or in early puberty. Thus, low growth hormone levels in response to stimulation testing cannot be taken as sole evidence of growth hormone deficiency. All told, Nutropin AQ injections are not medically necessary for the treatment of 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 methylprednisone. Findings:  The physician reviewer found that in the documentation available for review, although the patient gives an extensive history of multiple medical conditions, the patient does not currently have one of the diagnoses listed by the U.S. Food and Drug Administration (FDA) for the use of methylprednisolone taper. In addition, studies noted that no data on the efficacy and safety of systemic corticosteroids in residual pain in inflammatory arthritis could be identified from the literature. Moreover, the patients records do not include a thorough physical examination and complete treatment plan for her conditions. Such a work-up may include seeing a rheumatologist and possibly being started on different medications that do not have the same side effect profile as methylprednisolone. All told, the requested methylprednisone is not medically necessary for treatment of this patients medical condition. 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 anesthesiology with sub-specialty certification in pain medicine 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: The patient has requested reimbursement for inpatient hospitalization services. Encephalitis is a neurological syndrome caused by inflammation of the brain parenchyma (Britton, et al.). Treatment is challenging due to rapid disease progression, a broad differential diagnosis, and a lack of definitive treatment. The records provided for review document that this patients providers determined that he was stable for transition to a less acute level of care. The records document that the patient had no further neurologic work-up planned that would have required continued hospitalization. The patients diagnoses included right ischium and heel pressure ulcer, urinary retention, hypertension, hyponatremia, and Clostridium difficile. The patient did not require acute care or the intensity of services provided at the inpatient hospitalization level of care. Therefore, the inpatient hospitalization services were not medically necessary for treatment of this patient. Final Result: The reviewer 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: The reviewer is board certified in neurology 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 a consultation with a transplant hepatologist and blood tests (lipoprotein, anion gaps, bilirubin, albumin and total protein, alkaline phosphate, gamma-glutamyl transferase (GGT), and prothrombin time (PT)).According to Kwo and colleagues, work-up for underlying liver disease is appropriate given the risk of eventual cirrhosis and subsequent complications of decompensated cirrhosis, and the need to intervene on modifiable liver disease before the development of cirrhosis or end-stage liver disease. All of the requested tests (lipoprotein, anion gap, bilirubin, albumin and total protein, alkaline phosphatase, gamma-glutamyl transferase, and prothrombin time) are used in the assessment of liver disease, liver disease activity, hepatic function, or liver fibrosis level. In this case, the patient has elevated liver enzymes. However, the patient does not have an indication for consideration of liver transplantation and has been evaluated by a transplant hepatologist on 3/09/21, with lack of evidence of chronic liver disease on extensive laboratory testing. For these reasons, the blood tests (lipoprotein, anion gaps, bilirubin, albumin and total protein, alkaline phosphate, gamma-glutamyl transferase (GGT), and prothrombin time (PT)) are medically necessary for the evaluation of the patients medical condition. However, a consultation with a transplant hepatologist is not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are partially medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: An enrollee has request requested authorization and coverage for left knee injections with Orthovisc for treatment of osteoarthritis on his left knee.  Findings: The physician reviewer found that medical guidelines and literature support repeated cycles of viscosupplementation treatment to delay time to total knee replacement in patients with knee osteoarthritis which failed conservative treatment.  There is no maximum amount of injections established by high quality scientific evidence. In this case, the patient has been diagnosed with left knee osteoarthritis. He has undergone two prior viscosupplementation series, with positive results documented in terms of significant pain reduction and improved function. He is currently reporting progressive worsening of his knee pain and difficulty in gait. He reported that he was unable to take anti-inflammatory medications and did not want to take pain medications. He reported inadequate relief with prior physical therapy. The medical evidence supports the requested services in this clinical setting.  All told, the requested left knee injections with Orthovisc are 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 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 53-year-old female enrollee requested Sovaldi 400 mg and Olysio 150 mg capsules for 12 weeks for medical treatment of her Hepatitis C virus (HCV).  Findings:  Two physician reviewers found that the submitted documentation fails to establish the medical necessity of the requested medication combination. The requested combination of Sovaldi and Olysio has not been approved by the U.S. Food and Drug Administration (FDA). Although the requested treatment of simeprevir and sofosbuvir has been suggested by the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines it has not been studied in a large phase III trial. Therefore, the medical necessity of the requested medication combination has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee requested authorization and coverage of an MRI of the lumbar and thoracic spine for the treatment of generalized weakness and difficulty walking.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 63-year-old female with osteoarthritis in both knees. She was previously treated with a series of Synvisc injections in June 2004 with reported benefit. The patients provider has recommended another series of injections. The Health Plan indicates the requested injections are not medically necessary. The patient has already had three Synvisc injections. Based upon the information provided, it does not appear she has received steroid injections. Steroid injections are the appropriate next step for treatment of this patient. Additional Synvisc injections are not medically indicated at this time. The Health Plans recommendation of corticosteroid injections is medically reasonable and appropriate. Therefore, I have determined the requested injections are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested authorization and coverage for a full body DEXA scan.  The health plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees Musculoskeletal/orthopedic condition.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested service is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an insulin pump for treatment of the enrollees uncontrolled type 2 diabetes. Findings:  Two physician reviewers found that the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Insulin pump therapy and multiple dose insulin (MDI) regimen use in patients with type 2 diabetes has not shown significant difference in glycemic control. A study evaluated the safety of a hybrid closed-loop system in patients with type 1 diabetes. The authors concluded that, Longer-term registry data and randomized studies are needed to further characterize the safety and efficacy of the hybrid closed-loop system. At this time, the incremental benefit of automated closed-loop control of insulin administration is unclear. There is a lack of long-term data available demonstrating health outcome benefits of such technology compared to other treatment methods, including multiple daily injection therapy and continuous insulin infusion therapy with or without a threshold suspend device. The requested MiniMed system is not clinically indicated given the lack of long term studies of this system and lack of data to show it is beneficial for treatment of patients with type 2 diabetes. For the reasons provided, the requested insulin pump is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested device 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. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Oncotype DX Prostate Cancer Assay testing for evaluation of his medical condition.  Findings:  Two physician reviewers found that the Oncotype DX Prostate Cancer Assay is a real time polymerase chain reaction (RT-PCR) assay designed for analysis of prostate core needle biopsies. The assay measures the expression of 17 genes to calculate a GPS. The National Comprehensive Cancer Network (NCCN) guidelines in regards to Oncotype DX testing state Their clinical utility awaits evaluation by prospective, randomized clinical trials, which are unlikely to be done. The marketplace and comparative effectiveness research may be the only means for these tests and other like them to gain their proper place for better risk stratification for men with clinically localized prostate cancer. While Oncotype DX may eventually have a role in making treatment decisions for patients with prostate cancer, there is limited data on clinical outcomes to currently support its use. All told, the services at issue were 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 services at issue were 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 reviewers are board certified in urology 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 20-year-old male with persistent low back pain. The patient has requested coverage for chiropractic care. The Health Plan has recommended physical therapy. The patient reports he has intolerance to NSAID medication. At issue is whether chiropractic services are medically necessary for treatment of the patients condition.A persisting diagnosis of low back pain is a common presentation during a chiropractic consultation. It is also a common diagnosis treated with chiropractic care with favorable results. A trial approach of six chiropractic treatments is medically appropriate for this patient. If the patient experiences documented improvement with chiropractic treatment additional treatments should be authorized. Accordingly, I have determined the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.