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

This is an unusual case of a 28-year-old male with cystic fibrosis who is status post living lobar lung transplantation eight years ago. The transplant was bilateral from a living donor of one lobe each side. Apparently the patient has done well in the interval and is now working. The patient has recently developed an episode of sinusitis. The patient has requested authorization and coverage for a referral to a pulmonary specialist with experience and affiliation with a lung transplant center. The submitted documentation indicates the patient has been treated by the same providers at a transplant center for the past eight years. Because of the unusual circumstances of this case the patient should continue to be followed by a pulmonary specialist at a lung transplant center. Furthermore, continuity of care at a single center with the same team of physicians is in the patients best interest. The complexity and complications of the patients treatment are best remembered and best understood by the physicians who administered the treatment and who were there for the complications. Moreover, in cases where the patient is receiving treatment for a chronic illness, care is better in patients who have a consistent provider of care. In light of these factors, continued care from the patients treating providers at the lung transplant center from which he received his transplant is medically indicated. Based upon the information set forth above, I have determined that the requested referral is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old female enrollee has requested for 16 doses of Imitrex 6 mg per month for treatment of her migraine headaches.  Findings:  The physician reviewer found that studies of high frequency triptan use have not been performed, many observational studies support the concept of triptan rebound. Evidence suggests that use of triptans for more than three days a week will, over time, cause rebound headache. This is likely worsened by frequent narcotic analgesic use. Thus, the requested 16 injections of Imitrex a month is excessive and likely to cause rebound headache.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a four-year-old female enrollee has requested a comprehensive evaluation and participation in a one-week outpatient program (including, but not limited to, allergens, skin testing, laboratory testing, oral food challenges and nutritional evaluation) for the treatment of the enrollees allergies. Findings:  The physician reviewer found that the submitted clinical records, parents letters and physician letters do not document the medical necessity of a full evaluation and extended food allergy testing performed. Records indicate the patient has undergone IgE RAST annually, as well as skin testing, with several strong reactions. The patient is avoiding these foods. The letter from the patients parents states the patient has experienced ingestion, inhalation and contact reactions. These types of reactions are not evidence of life-threatening anaphylaxis, and are not documented by physical findings. The patients parents are seeking extensive oral challenge testing to foods for which the patient has had equivocal test results. However, the submitted records do not document the presence of life-threatening anaphylaxis on any occasion, for which oral challenge testing in a carefully controlled setting may be considered warranted. In addition, the records do not document that the patient could not receive appropriate oral challenge testing from an in-network provider. There is no medical necessity to seek an additional evaluation for food allergies and the patients additional diagnoses of inhalant allergy, asthma and eczema at the outpatient program.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a continuous positive airway pressure (CPAP) device for treatment of the enrollees mild obstructive sleep apnea. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested device. The patients Epworth Sleepiness Scale score was normal. Per the records, he does not have clinically significant hypersomnia which is a cornerstone for a diagnosis of sleep apnea. Despite that finding, he had a sleep study. The patient does not have a history of hypertension, heart disease or a stroke. In the absence of hypertension, cerebrovascular accident or cardiac disease, the criteria for the medical necessity for CPAP is an apnea-hypopnea index of 15 or higher. In this patients case, his apnea-hypopnea index was 6.0. There was one sleep position during which his AHI was 9.4, but that is not the criteria measurement. Specifically, the criteria measurement is the apnea-hypopnea-index for the entire sleep study. The current medical evidence does not support the requested device in this clinical setting. All told, the requested CPAP device is not medically necessary for the 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 internal medicine with sub-specialty certification in pulmonary 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization program services. In cases such as this, an evidence-based, objective instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 1 due to a lack of current suicidal ideation and no self-harming behaviors. With regards to functional status, the records support a score of 2 due to an overall good functional level with appropriate activities of daily living. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability with stable psychiatric symptoms. With regards to level of stress of the recovery environment, the records support a score of 2 due to no mention of a stressful recovery environment. In terms of level of support of the recovery environment, the records support a score of 2 due to family support and availability of treatment resources. With regards to treatment and recovery history, the records support a score of 2 due to success in the recent wilderness residential treatment program with a good level of cooperation and stabilization of symptoms. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment and insight into the need for treatment.  This score correlates with low intensity community-based services. Therefore, partial hospitalization program services were not medically necessary for the 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 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

The patient is a 49-year-old man who has erectile dysfunction. The patient received a temporary prescription of Viagra, which reportedly improved his condition. In addition, review of the submitted records indicates the patient has received multiple medications for treatment of depression including Lorazepam, Wellbutrin, Desipramine, Ativan and Adderall. The patient has requested authorization for a consultation with an urologist for treatment of his erectile dysfunction.Viagra is accepted primary therapy for erectile dysfunction. Treatment of erectile dysfunction is goal directed. Whatever treatment is successful and acceptable to the patient has his partner is appropriate therapy. The patient has depression and is being treated with anti-depressants. The fact that the patients anti-depressive medication has a known side effect of erectile dysfunction should not preclude appropriate treatment of his erectile dysfunction. The patient should have a urology consultation and the urologist and the patients psychiatrist should coordinate care so that appropriate adjustment to the patients medications can be made in order to treat both the patients depression and erectile dysfunction. These two conditions are potentially contributing to each other and both need to be addressed. Based upon the information set forth above, I have determined that the requested consultation is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A forty-nine year-old male with symptomatic chest pain is requesting reimbursement for a CT angiography (CTA).  Reviewers Findings:  Two of the three reviewing physician found that the CTA is appropriate for a symptomatic patient when there is an uninterpretable or equivocal stress test. In this instance the patients stress test was equivocal, establishing a valid basis for the application of CTA.  The third physician found that the CTA is considered investigational in most applications and is not a substitute for cardiac catheterization or nuclear SPECT imaging.  The reviewing physicians found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier for treatment of the enrollees 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 recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1b patients should be treated with regimens including or Zepatier, based on clinical trial results showing a 99% cure rate regardless of nonstructural protein 5A (NS5A) resistance. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 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: Medical Necessity
Decision: Upheld

A 46-year-old male enrollee has requested a bone growth stimulator for treatment of his Jones fracture of the fifth metatarsal.  Findings:  The physician reviewer found that a bone growth stimulator is not medically necessary for treatment of this patients medical condition. Although the patient has a Jones fracture, there is a lack of evidence of delayed healing as demonstrated by bone loss of 15 mm or less has no clinical signs or radiographic findings of delayed progress toward healing. This patients records indicate he has a non-acute left fifth metatarsal fracture with signs of progress toward healing. The most recent x-ray showed progressive union and the presence of new bone growth visible at the fracture site. Thus, the patient does not meet the Milliman Care Guidelines for a bone growth stimulator and the requested device is not medically necessary for treatment of his medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 20-year-old male enrollee requested authorization and coverage of a bilateral thoracic sympathectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees hyperhidrosis.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

A 63-year-old female enrollee has requested Orthovisc injections (hyaluronate injections) for treatment of her bilateral knee arthritis. Findings:  The physician reviewer found the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested therapy. There is a lack of adequate randomized, controlled studies demonstrating the clinical effect from hyaluronate injections. Rutjes and colleagues assessed the efficacy of viscosupplementation for adults with symptomatic knee osteoarthritis. This study concluded after review of a total of 89 trials involving 12,667 adults that in patients with knee osteoarthritis viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects (Rutjes et al). Moreover, the American Academy of Orthopaedic Surgeons practice guidelines for the treatment of osteoarthritis of the knee states, We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. Finally, several studies evaluating repeated treatment protocols document adverse events including inflammatory changes within the knee joint and in some cases requiring arthrocentesis after multiple injections. Given the reasons provided, the requested therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a cryotherapy machine/device (Kodiak combo cold therapy unit) by Pacific Medical Inc. Cold applications are well understood as helping to decrease pain following shoulder replacement surgery. However, researchers report that there does not appear to be a significant benefit to the use of compressive cryotherapy over standard ice wrapping in patients undergoing shoulder arthroscopy for rotator cuff repair or subacromial decompression. Given that current medical literature does not support the use of a motorized unit versus the self-application of cold packs, the equipment at issue was not medically indicated. Therefore, the cryotherapy machine/device (Kodiak combo cold therapy unit) by Pacific Medical Inc. was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the equipment at issue was 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xifaxan 550 mg. The U.S. Food and Drug Administration (FDA) approves the use of Xifaxan 550 mg three times daily for 14 days for the treatment of IBS-D. The American College of Gastroenterology (ACG) guidelines on the management of IBS recommend rifaximin to treat global IBS with diarrhea symptoms. Schoenfeld and colleagues report that rifaximin has been proven as safe and effective in randomized placebo-controlled trials for IBS-D. Lembo and colleagues report in a phase 3, randomized, double-blind, placebo-controlled trial with over 1,000 patients that Xifaxan proved effective, resulting in significant symptom improvement in IBS. In this case, the patient has a diagnosis of IBS-D, along with SIBO. According to Gatta and Scarpignato, rifaximin (brand name Xifaxan) treatment is effective and safe for the treatment of SIBO. In a prospective trial of patients with IBS and a positive breath test for SIBO, Moraru and colleagues reported that rifaximin effectively normalized the  glucose hydrogen breath test, and reduced IBS symptoms. Given that current medical literature supports the use of Xifaxan for the treatment of SIBO in the setting of IBS-D, the requested medication is medically indicated. Therefore, Xifaxan 550 mg is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Emgality autoinjector 120 mg/mL. The records provided for review document that this patient sustained facial trauma in an accident a few years ago that has required extensive surgery. The patient now presents with complaints of migraines. The provider charted that the patients migraine symptoms are no longer improved with gabapentin. The patients provider has recommended treatment with Emgality and topiramate. Migraine is an episodic disorder, the centerpiece of which is a severe headache generally associated with nausea and/or light and sound sensitivity. Emgality is a calcitonin gene-related peptide (CGRP) antagonist. Recent studies have reported that Emgality is safe and effective in preventative migraine management. Moreover, Emgality is U.S. Food and Drug Administration (FDA) approved for migraine prophylaxis. Given the established effectiveness and safety of Emgality as well as this patients history, the requested treatment regimen including topiramate and Emgality is appropriate. Therefore, the requested Emgality autoinjector 120 mg/mL is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurology with subspecialty certification in vascular 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

A 20-year-old male enrollee has requested a continuous passive motion machine for the treatment of his knee, status-post arthroscopy. Findings:  The physician reviewer found that there is sufficient medical literature supporting the use of CPM devices after various forms of knee surgery including chondroplasty and microfracture, to support the medical necessity of the device in this particular setting.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Epclusa 400 mg - 100 mg tablets for 12 weeks. The patient has been diagnosed with hepatitis C. American Association for the Study of Liver Diseases and Infectious Diseases Society of America reported, The daily fixed-dose combination of sofosbuvir (400 mg)/velpatasvir (100 mg) for 12 weeks was approved by the U.S. Food and Drug Administration (FDA) for the treatment of genotype 3 infection in patients without cirrhosis or with compensated cirrhosis. The authors also noted, The phase 3 POLARIS-2 study evaluated 12 weeks of sofosbuvir/velpatasvir in genotype 3-infected, noncirrhotic patients who were either treatment-naive or interferon-experienced. Eighty-nine genotype three patients received the sofosbuvir/velpatasvir regimen and 97% achieved a sustained virologic response (SVR)12. In this case, the patient has documented hepatitis C, genotype 3 infection. The patient has begun treatment with Epclusa, which is consistent with the recommended guidelines. The medical evidence supports the requested medication regimen. Therefore, Epclusa 400 mg - 100 mg tablets for 12 weeks are 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 in internal medicine with sub-specialty certification in infectious 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: Upheld

A sixty-three year-old male who was diagnosed with a T1c, Gleason 3+3=6, PSA 6.08 adenocarcinoma of the prostate is requesting reimbursement of proton beam radiation therapy.  Reviewers Findings:  The reviewing physician found that following national guidelines, proton beam radiation is not superior to photon beam radiation. IMRT and 3D conformal radiation are standard options that appeared to have been available from the Health Plan.  The reviewing physician found that the Health Plan denial should be upheld.