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 Epclusa for 12 weeks for treatment of the enrollees hepatitis C. Findings: The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment-naive, genotype 2 patients. A delay in treatment may result in decreased survival. For these reasons, Epclusa 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: Medical Necessity
Decision: Overturned

A 43-year-old female enrollee has requested for Lyrica for treatment of her condition. Findings:  The physician reviewer found that Lyrica has been approved for several neuropathic or chronic widespread pain disorders, including diabetic neuropathy, postherpetic neuralgia and fibromyalgia. Medications are tested on common disorders, but are routinely and appropriately used off-label for related disorders.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a 13-year-old female enrollee have requested speech therapy for the treatment of the enrollees tongue thrust. Findings:  The physician reviewer found that although there is some literature supporting the use of myofunctional/speech therapy to correct dentition, there is little to no evidence-based literature. In addition, it does not appear that this patient has any speech disorder. Therefore, it does seem that this problem is in fact behavioral in nature. In the absence of any studies showing the medical necessity of speech therapy for this clinical situation, the requested therapy cannot be supported.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee has requested 16 doses of Vivelle Dot per month for treatment of her medical condition status post surgical menopause. Findings:  Two physician reviewers found that there is a paucity of data to support the efficacy of increasing the dose of Vivelle Dot patch to every other day. Given the lack of scientific data establishing the long-term safety and efficacy of this increased dosage there may be additional risks and side effects that have not been determined. To date, the available medical publications do not show the increased dosage improves health outcomes. Further, the research does not suggest that replacing the Vivelle Dot patch every other day rather than twice per week is as good as, or better than standard alternative therapies. Since this elevated dose has not been established as safe and effective, its use in this instance remains investigational.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a mastectomy procedure for removal of gynecomastia on both breasts.At issue is whether the requested mastectomy procedure for removal of gynecomastia on both breasts is medically necessary to treat the patients medical condition. Does the condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital effects, developmental abnormalities, trauma, infection, tumors, or disease? If so, is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible? If so, does the surgery provide more than a minimal improvement in the appearance of the patient?The American Society of Plastic Surgeons notes that excision of gynecomastia may be indicated when malignancy is suspected, when grade II or grade IV gynecomastia is present, or when there is pain and discomfort due to the distention and tightness from the hypertrophied breast. In this case, the patient has 1.5 centimeter retroareolar masses which appear to be consistent with grade I gynecomastia. Malignancy is not suspected. He does not complain of pain and discomfort due to distension and tightness from the hypertrophied breast, although he complains of pain while wearing his body armor as a police officer. Therefore, the requested mastectomy procedure for removal of gynecomastia on both breasts is not medically necessary to treat the patients medical condition.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. Gynecomastia constitutes an abnormal structure of the body due to a developmental abnormality. In this patients case, excision of the gynecomastia would be performed to improve function. Per the submitted documentation, the recurrent gynecomastia causes pain when the patient wears a bulletproof vest as a necessary part of his employment as a police officer. Accordingly, the requested mastectomy procedure for removal of gynecomastia on both breasts is reconstructive in nature. Final Result: The reviewer determined that the requested service 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 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: Overturned

A 61-year-old male enrollee requested the medication combination Sovaldi 400mg and Olysio 150mg for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that the submitted documentation supports the medical necessity of the requested medication combination.  Based upon examination, laboratory testing, radiology evaluations, and endoscopy, the patient has cirrhosis.  He is not eligible for interferon-based regimens due to depression and severe thrombocytopenia.  This patient would benefit from eradication of hepatitis C, as his risk for further decompensation and hepatocellular carcinoma will be attenuated.  All told, the requested medication combination Sovaldi 400mg and Olysio 150mg is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 35-year-old female with a history of miscarriage and premature delivery due to a premature rupture of membranes at 24 weeks of twins with perinatal demise of both. She has a history of irregular menstrual cycles and required fertility medication with IUI for conception. A note in the history confirms the diagnosis of polycystic ovarian syndrome. Another notation reports an elevated serum homocysteine level, but no documentation of this has been provided. The patient was referred to a reproductive endocrinologist who initiated a workup for immunologic testing for recurrent pregnancy loss. Antithyroid antibodies and NK cell assays were positive, and the patient was homozygous for MTHFR. Levoxyl, low dose aspirin, prometrium, Lovenox, metformin and high dose folic acid were prescribed for preconception purposes and for pregnancy. A subsequent pregnancy was naturally conceived. The reproductive endocrinologist continued to follow the patient through the first and second trimesters. Lymphocyte immunophenotype assays and NK cell assays by flow cytometry and THI:TH2 cytokine ratios were obtained, some on a serial basis. IVIG therapy was given. During this time a mildly elevated NK killing capacity was found. At issue in this case is whether these immunologic assays were medically necessary for evaluation and treatment of the patients condition.This patient was given a diagnosis of recurrent pregnancy loss in the first and second trimester. A clear diagnosis of polycystic ovarian syndrome is noted. The referral to a reproductive endocrinologist was within the standard of care. Metformin treatment for this syndrome is also within the standard of care. During the workup, testing for auto and alloimmune disorders was performed, uncovering evidence of homozygous MTHR and antithroid antibodies. Both of these are associated with recurrent loss in the medical literature. Further testing during pregnancy for NK cell activity during the pregnancy and its treatment is not presently within the standard of care, as there have been no clear benefits shown. The American College of Obstetrics and Gynecology states in its Practice Bulletin that: in the absence of a proven effective treatment, tests for determination of the percentage of circulating NK cells in women with recurrent pregnancy loss is not beneficial. Given that the NK assay and cyclometry studies at issue are without clinical benefit in this setting, the Health Plans denial is appropriate.Based upon the information set forth above, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 27-year-old male enrollee has requested Azilect 2 mg per day for treatment of his hand tremor secondary to several anti-depressant medications. Findings:  Three physician reviewers found that there is a paucity of medical literature supporting the use of Azilect in the treatment of either major depressive disorders (MDD) or antidepressant induced tremor. The only indication for Azilect, according to currently accepted evidence-based practice standards and expert consensus, appears to be Parkinsons disease (Nayak and Henchcliffe). In addition, the current Physicians Desk Reference (PDR) cautions that Azilect is potentially dangerous when used in conjunction with antidepressants. This patient does not have a documented diagnosis of Parkinsons disease and the peer reviewed scientific data fails to support the use of Azilect in the treatment of either MDD or antidepressant induced tremor. For these reasons, Azilect is not likely to be more effective than standard therapy for this patients condition and has not been established as safe for this indication.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a female enrollee requested Genotropin for treatment of her medical condition.  Findings:  Two physician reviewers found that the patient has short stature and a history of significant weight loss due to inflammatory bowel disease.  Given that this patients bone age is delayed and she is only in early puberty, her adult height prediction has the potential to improve with effective treatment of her underlying inflammatory bowel disease.  In sum, the requested Genotropin is not likely to be more effective than other treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 14-year-old male enrollee has requested residential treatment for treatment of the enrollees major depressive disorder, recurrent, mild, oppositional defiant disorder and intermittent explosive disorder.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue. A recent article by Wilmshurst provides research evidence indicating that children with attention deficit/hyperactivity disorder do better when treated in the community with their families.  Per the submitted documentation, there is no indication of risk to self or others requiring containment on a 24-hour basis.   Per the submitted medical records, the patient received approximately five to ten hours of programming per week which were conducted by therapists, with occasional visits by a psychiatrist.  However, there is no indication that the psychiatrist provided direct input into treatment planning.  American Psychiatric Association guidelines were not met, as there is no indication that the patient could not have been safely and effectively managed in the context of a less restrictive setting.  The services provided at the residential treatment center during the said time frame were not medically indicated according to current standards of evidence-based practice and expert consensus. The patient could have been managed with outpatient psychotherapy and medication management during this time.  All told, services provided were not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old male enrollee has requested Flector patch for treatment of his chronic low back pain. Findings:  The physician reviewer found that based on the records provided for review, the requested Flector patch is not medically necessary for treatment of the patients medical condition. There is no documentation of gastrointestinal (GI) irritation with oral non-steroidal anti-inflammatory drugs (NSAIDs). In the medical literature, oral NSAIDs are contraindicated in patients who have a side effect of GI irritation due to increased risk of gastric ulcers and gastric perforation. Further, the Flector patch is not medically necessary because it is not equally or more effective than other appropriate alternative oral medications that may treat this patients chronic pain. In the medical literature, Haroutiunian and colleagues performed a systematic review to address and summarize the evidence of effectiveness and safety in topical NSAIDs. The authors concluded that topical NSAIDs may vary significantly in their absorption kinetics and pharmacodynamic effects based on their molecule and the formulation chosen. Lin and colleagues performed a meta-analysis of randomized controlled trials comparing topical NSAIDs with placebo. The authors found that topical NSAIDs were superior to placebo in relieving pain due to osteoarthritis only in the first two weeks of treatment. The study concluded that after two weeks, there was no evidence of efficacy superior to placebo. Overall, in acute and chronic low back pain, widespread musculoskeletal pain, and in peripheral neuropathic pain syndromes, the current evidence does not support the use of topical NSAIDs. Consistent with these findings, the requested Flector patch is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 26-year-old male enrollee has requested pulsed radiofrequency neurolysis for the treatment of his primary supraorbital and primary trochlear headaches. Findings:  Three physician reviewers found that radiofrequency nerve blocks are considered investigational treatment for headaches, and this form of treatment is not standard of care. There is no evidence to support radiofrequency nerve blocks as medically necessary or effective for treatment of this patients condition. Furthermore, there is no clinical evidence that this patient has exhausted available standard treatment options. Even if the patient has exhausted standard treatment options, radiofrequency nerve blocks would not be considered appropriate for treatment of his medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 58-year-old woman who has psoriasis of her scalp, ears, torso and upper extremities. Treatment with appropriate topicals is painful and severely itchy because of the psoriasis. Methotrexate therapy was stopped because of an abnormal liver function test. The patient indicates the nearest ultraviolet treatment facility is not practical because of the long travel time that would be involved, many times per week. It has been stated that the psoriasis covers 15% of the patients body surface. A request has been made for authorization for Raptiva. The Health Plan has denied this request indicating Raptiva is not medically necessary for treatment of the patients condition.Ultraviolet treatment for this patient is impractical, unless a treatment center near the patient is located. Topicals were ineffective. In addition, methotrexate, cyclosporine and Soriatane are contraindicated because of the patients abnormal liver function tests. According to medically accepted guidelines, it appears the body surface area involved in this case is at least 50%, the scalp at least 67%, and the trunk at least 30%. Thus, the patients psoriasis requires further treatment. However, given the respective safety profiles of Enbrel and Raptiva, Enbrel would be the medically appropriate next step in the patients regimen. Thus, the use of Raptiva is not medically warranted at this time. Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld. However, if treatment with Enbrel is requested by the patient and her provider, it would be medically appropriate and should be authorized.
Appeal type: Experimental/Investigational
Decision: Overturned

A female enrollee requested a colon motility study (91117, six hour study) for medical evaluation of her slow transit constipation, abdominal pain, non-ulcer dyspepsia, and rectocele.  Findings:  Two physician reviewers found that this patient has evidence of slow colonic transit by defecography and has remained with persistent constipation despite medical management. In this clinical setting, colonic manometry can identify the cause of constipation in well selected patients. Given these findings, the requested colon motility study (91117, six hour study) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old male enrollee requested authorization and coverage of cataract surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees cataract.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hip replacement surgery. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee who has a history of hip pain.Findings: Nationally recognized evidence based medical guidelines recommend total hip arthroplasty when all reasonable conservative measures have been exhausted and other reasonable surgical options have been seriously considered or implemented. The criteria include conservative care with exercise therapy, medications, and documented significant weight loss effort with BMI greater than 30. It was noted that surgery should be delayed a minimum of three months, preferably one year following any intra-articular corticosteroid injection due to increased risk of periprosthetic infection. Subjective findings should include limited range of motion, or nighttime joint pain, or no pain relief with conservative care. Objective findings should include over 50 years of age and a BMI less than 35 as increased BMI poses significantly elevated risks for post-operative complications. Imaging findings of osteoarthritis on standing x-rays or arthroscopy are required. A review of a total of 10,690 primary total hip arthroplasties and concluded that obesity was one of the most important modifiable patient factors in predicting periprosthetic joint injection following total hip arthroplasty. This patient reported a two year history of ongoing left hip pain with a constant grade of 5 out of 10 pain with medications. However, evidence based medical guidelines and peer-reviewed literature indicate that an elevated BMI poses significantly increased risks for post-operative complications and recommend a BMI of 35. Additionally, guidelines recommend that total hip replacement be delayed at least three months following corticosteroid injection due to the increased risk of periprosthetic infection. An orthopedic report indicated the patient underwent a left hip corticosteroid injection. While the patient has lost weight, her BMI is still significantly elevated. Accordingly, the records do not present a compelling rationale to support the medical necessity of total hip replacement in the setting of an elevated BMI and within three months of corticosteroid injection. Therefore, the requested services are not medically necessary in the treatment of the patients medical condition. Final Result: The reviewer 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: 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a power wheelchair to perform one or more mobility related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community. Researchers note the possibility that the sedentary nature of power wheelchair usage results in a decline of physical functionality and therefore reduced capabilities in their users. In this case, the patient has a diagnosis of paraplegia. His upper extremities were weak from deconditioning, but were neurologically unaffected by his lower extremity paraplegia and with the appropriate therapy program were expected to improve. The records do not show evidence of a recent therapy program for the upper extremities to strengthen and condition for manual wheelchair use, or of a concrete discharge plan at this time. While a manual wheelchair with tilt in space may be appropriate in the future when the patient is able to self-propel, a power wheelchair is not currently indicated. Therefore, a power wheelchair is not medically necessary to perform one or more mobility related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community. Final Result: The reviewer determined that the requested equipment 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 with sub-specialty certification in neuromuscular 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.