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

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested a residential treatment center (RTC) for treatment of the enrollees mood disorder and conduct disorder.  The physician reviewer found that the patient is described as being cooperative and fully participating in individual, group, and recreation therapies. There were no documented medical issues, and his medications had remained stable for at least two months. He had some limited insight into his issues. However, he was not a danger to himself or others, he was able to fully perform all activities of daily living, and was cooperating in all therapeutic modalities. He did not meet criteria for stay in the RTC level and could have been safely discharged to a lower level of care.   Therefore, the medical records do not support the medical necessity of the RTC services at issue.  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 with sub-specialty certification in child and adolescent 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: Upheld

A 62-year-old female has requested Tekturna for treatment of her proteinuria.  Findings:  The physician reviewer found that the patient has minimal change disease (MCD) with significant proteinuria and hypertension (HTN), which is best treated initially with an angiotensin converting enzyme (ACE) inhibitor) and if blood pressure allows, an ARB. The role of Tekturna in treatment of HTN is still unclear, given that outcome studies have not yet been performed and clinical experience is limited concerning possible side effects. Specific to treatment of HTN in MCD, the use of an angiotensin converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) seems a reasonable option for blood pressure reduction, and may have the added benefit of reducing urinary protein excretion. Thus, the use of Tekturna in this setting is not the standard of care. While it might provide some reduction of blood pressure and proteinuria if an additional antihypertensive agent is required, the use of an ARB should be attempted prior to the use of Tekturna.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient is requesting Tremfya injections. Findings:  The physician reviewer found that there is no documented contraindication to the use of formulary alternatives such as Humira, Enbrel or Cosentyx. Therefore, Tremfya100 injections are not medically necessary for the patient. The Health Plan has denied the requested medication as the Health Plan has approved formulary alternatives, Humira, Enbrel and Cosentyx. At issue in this case is whether Tremfya injections are medically necessary for treatment of the patients medical condition. According to the American Academy of Dermatology and the National Psoriasis Foundation, formulary alternative medications such as Humira, Enbrel and Cosentyx, are safe and effective for the treatment of psoriasis (Menter, et al.). An analysis of Enbrel showed that at week 12, patients receiving Enbrel, achieved a 75% improvement on the psoriasis area severity index (PASI) compared with those receiving placebo. Analysis of Humira showed that at week 40, the rates of achievement of PASI 75 and PASI 90 among patients treated with Humira were 67% and 40%, respectively. Analysis of Cosentyx versus placebo showed that the percentage of patients who achieved PASI 75 at week 12 was higher with each Cosentyx dose than with placebo. This patient has failed treatment with Stelara. However, there is no documented contraindication to the use of formulary alternatives such as Humira, Enbrel or Cosentyx. Therefore, Tremfya100 mg/mL injections are not medically necessary for the patient. 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 dermatology 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 Computed Tomography (CT) of the abdomen, without contrast material.Findings: Hirsutism is a clinical feature of polycystic ovarian syndrome. However, it can also be a feature of adrenal lesions. Adrenal imaging is indicated to look for an adrenal mass if a patient has a markedly elevated serum dehydroepiandrosterone sulfate (DHEA-S) concentration that is greater than 700 mcg/dL [18.9 micromol/L]. If imaging is indicated, then Computed Tomography (CT) is the modality of choice. Adrenal incidentalomas are a common cause of nonfunctioning adrenal masses and can be incidentally found on imaging. Therefore, radiologic testing is not indicated and may be misleading when the required DHEA-S concentration is not met. The patients lab results indicate that their dehydroepiandrosterone (DHEA) levels are elevated at 435, but they are still under the criteria indicated for radiologic testing. Under these circumstances, the requested Computed Tomography (CT) of the abdomen, without contrast material is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for the patients medical condition. Therefore, the Health Plans denial should be upheld.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: Medical Necessity
Decision: Overturned

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services.  Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. The patients meets the criterion for dimension 1, as the records document mild to moderate withdrawal symptoms including pulse rate ranging from 81-120, paroxysmal sweating, bone and joint aches, and tremor. For dimension 2, the patient has ongoing tremor and remains at risk for overdose when not supervised. Dimension 3 is also met given the patients PTSD, depression and anxiety with suicidal ideation. The presence of these comorbid conditions place the patient at higher risk for continued substance abuse. For dimension 4, the patient has demonstrated mood swings, irritability, and recent heavy use. He requires a higher level of accountability and although he is somewhat willing, he is not yet fully able or ready. Dimension 5 is satisfied considering the patients reports of cravings to use, prior relapses, and compulsive behaviors. The provider noted that due to the patients ongoing psychiatric symptoms and ambivalence about utilizing the skills provided, he remains at high risk for relapse. For dimension 6, the patients social network is comprised of friends who use. Prior premature release to this recovery environment has led to recurrent relapse. The patient requires a safe and stable living environment in order to develop his recovery skills. Based on the records, the patient qualifies for ASAM Level III treatment, at least similar to what patient has been receiving at the current RTC facility. Given the severity of the patients illness, the RTC services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 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 33-year-old female enrollee requested authorization and coverage of breast reduction surgery. The Health Plan denied the request indicating that the requested surgery is not medically necessary for treatment of the enrollees excessive breast tissue.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: The patient has requested authorization and coverage for excess skin removal procedures for stomach and thighs for treatment of the enrollees excess skin and not reconstructive in nature. Findings:  The physician reviewer found that The requested panniculectomy is not medically necessary for treatment of this patients medical condition. The medical records do not provide any documentation of an ongoing clinically significant dermatologic problems that have either never responded to physician directed topical therapy or despite initial response, have recurred and caused significant functional impairment. Overall, supervised medical management for rashes is not documented in any of the progress notes. Further, the patient is not sick from her excess skin, and has not had ulcerations, panniculitis or sepsis from her infections. A dermatologist has not reportedly evaluated the patients rashes and the patient has not required hospitalization or treatment with intravenous or oral antifungal or antibiotic medications. As noted in the medical literature, medically supervised treatment is the most appropriate method for managing this patients problems, and conservative treatment with appropriate hygiene and topical medications has a reasonable likelihood of correcting the condition. In a multiple regression analysis of postoperative complications after body-contouring surgery written by Parvizi and colleagues, the authors found that the overall rate for major complications that required operative revision and/or antibiotics was 10.2%. In addition, 41% had minor complications, such as seromas, hematomas, wound healing problems, and wound dehiscences. Therefore, conservative, non-operative treatment is recommended, such as improved hygiene, topical creams or powders, and watchful waiting. Surgical lipectomy is reserved for patients that have failed optimal medical management for intertrigo, which is not documented to be the case for this patient. In addition, the patients condition does not constitute an abnormal structure of the body as an abdominal pannus is an expected consequence of weight loss. Moreover, the requested surgery is not likely to provide more than a minimal improvement in the patients appearance. Thus, the requested panniculectomy is not reconstructive in nature or medically necessary.Final Result: The reviewer determined that the requested surgery is not medically necessary or reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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: Experimental/Investigational
Decision: Upheld

A sixty-one year old male enrollee requested authorization and coverage of the medication Gleevec. The Health Plan denied the request indicating that the requested medication is considered experimental for treatment of the enrollees multiple myeloma.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 surgery 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

The parent of a 15-year-old male enrollee has requested Genotropin 12mg injections for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that the submitted documentation fails to support the medical necessity of the requested therapy.  Although the patients height is more than two standard deviations below the mean for age and gender, information about growth velocity, pubertal stage, and bone age were not provided, so an accurate prediction of final adult height cannot be made. Furthermore, it cannot be determined whether constitutional delay of growth and development is the cause of the patients short stature rather than growth hormone deficiency. No information is provided to confirm that other causes of poor growth, including poor caloric intake and malabsorption, were ruled out. The patients target genetic potential is not mentioned. Provocative growth hormone testing was not performed, and the patient is not reported to have other signs of pituitary deficiency or a morphologic abnormality of the pituitary gland.  All told, Genotropin 12mg injections are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old male enrollee requested authorization and coverage of the medication rebif for the treatment of multiple sclerosis .  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 medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus. Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per the guidelines, treatment-naive non-cirrhotic genotype 1a patients should be treated with Harvoni. The guidelines report that Harvoni for eight weeks is appropriate in patients with viral load of below 6,000,000 IU/mL. These guideline recommendations are based on multiple randomized clinical trials.  The guidelines cite study data reporting that delay in treatment is associated with decreased survival. For these reasons, the requested Harvoni is supported as 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lyrica. In the peer-reviewed medical literature, researchers reviewed the efficacy of Lyrica for neuropathic pain in adults. The authors concluded that studies showed limited evidence of benefit in neuropathic back pain or sciatica, neuropathic cancer pain, or polyneuropathy. In addition, the North American Spine Society (NASS) guidelines reported a lack of strong evidence to recommend Lyrica for lumbar radiculopathy. In this case, the patients history consists of chronic right lumbar radiculopathy status post lumbar laminectomy and fusion in 2017, with current symptoms of numbness and radicular pain to the right leg. The patient has tried and failed physical therapy as well as gabapentin and ibuprofen. Treatment with Lyrica reportedly improved the patients pain. However, the providers notes do not state that the patient has undergone an adequate trial of neuropathic agents from other drug classes which have been proven to be effective for this patients medical condition. Currently, the U.S. Food and Drug Administration (FDA) has not approved Lyrica for lumbar radicular pain. Based on these findings, the requested Lyrica is not supported as medically necessary for 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 anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 78-year-old male who underwent cardiac transplant for class III-IV congestive heart failure. He has multiple comorbidities including carotid artery disease, pancytopenia, prostate cancer, asthma and proteinuria. He was accepted as a candidate for an alternate donor heart and the transplant procedure was performed in June 2005. The patient has request reimbursement for this procedure. The Health Plan has denied this request on the basis that the patient did not meet generally accepted medical criteria for transplantation.Review of the submitted clinical evidence demonstrates that the patient had end-stage heart disease that had become refractory to medical therapy. Though the patient had multiple medical problems, he did meet transplant criteria for inclusion in the alternate donor transplant program. An alternate donor transplant was performed in June 2005. Based on the patients condition at that time, an alternate donor transplant was medically necessary for the treatment of the patient. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested stereotactic body radiation therapy for treatment of his medical condition. Findings: Three physician reviewers found that stereotactic body radiotherapy is an accepted standard therapy for patients with early stage lung cancer. Studies have shown it is associated with a local control rate of greater than 90%, which is comparable to surgical outcomes. Furthermore, stereotactic radiotherapy is well documented to be superior to conventional radiation treatment with standard fractionation.  The patients decision to not undergo surgery is acceptable as many patients do not want to undergo an invasive procedure, or undergo the risks of general anesthesia. The alternative therapy in such a case is a non-invasive method of treatment of the cancer using stereotactic radiation. Therefore, the requested stereotactic body radiation therapy is likely to be more beneficial for the treatment of the patients condition than any standard therapy.   Final Result: Three reviewers determined that the requested services are 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: All three physician reviewers are board certified in radiation oncology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Calmare Scrambler therapy. Researchers report that neuropathic corneal pain (NCP) can be extremely challenging to manage, and evidence-based clinical recommendations for the management of patients with NCP are scarce. In providing guidelines for the diagnosis and treatment of patients with NCP, the authors do not mention Scrambler therapy as a management option. Researchers noted that while there is no consensus in potential treatment strategies of NCP, nortriptyline appears effective in relieving NCP symptoms in patients with centralized component and insufficient response to other systemic and topical therapies. In this case, the patient has reported ocular neuropathic pain and photophobia. Current medical literature does not support the use of Scrambler therapy in this clinical setting. Therefore, Calmare Scrambler therapy is not likely be more beneficial than any other available standard service for the patients medical condition.Findings:  Three of the three physician reviewers found the requested Calmare Scrambler therapy 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 service 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: Physician reviewers 1, 2, and 3 are board certified in ophthalmology 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.