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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for 40 hours per week of home skilled nursing services. In a study of 33 families of children with life-limiting diseases requiring an average of five different life-supporting medical appliances, researchers noted that parents spent an average of nine hours daily on caregiving, with the most time-consuming daily needs being feeding and support when the child woke up at night. Current data shows that the number of medical appliances is correlated proportionally with a greater amount of time needed for the childs care. Researchers note that extraordinary and diverse needs are common among family caregivers of medically complex children with special health care needs and that enhanced care coordination support, respite care, and direct home care may address the burdens and unmet needs of these families. While appropriate daily support is important, in this case, the records do not document multiple chronic conditions or life limiting diseases that make this patient dependent on skilled caregivers and the use of complex medical appliances. The records do not reflect that the patient requires highly complex medical care at home or requires several procedures that have to be expertly managed. In this clinical setting, while there is a daily burden of care on the caregivers, the requested services are not medically indicated. Therefore, 40 hours per week of home skilled nursing services are not medically necessary to prevent disease, disability, and other health conditions or their progression.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 physical medicine and rehabilitation with sub-specialty certification in pediatric rehabilitation 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: Overturned

The patient has requested authorization and coverage for Stelara 90 mg every four weeks. The patient has been diagnosed with Crohns disease of the ileum and abdominal pain. Medical literature states that patients with moderate-to-severe Crohns disease that was resistant to tumor necrosis factor (TNF) antagonists had an increased rate of response to induction with ustekinumab, as compared with placebo. Patients with an initial response to ustekinumab had significantly increased rates of response and remission with ustekinumab as maintenance therapy. In this case, the patient has tried and failed multiple biologic and conventional alternatives and had disease symptoms on Stelara dosing every eight weeks. The patient had a low Stelara level and lack of anti-Stelara antibodies. The medical evidence supports the requested medication regimen in this clinical setting. Therefore, Stelara 90 mg every four 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C virus (HVC).  Findings:  Two physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related conditions.  In treatment-naive genotype 1 patients, therapy is recommended with Harvoni for 12 weeks as a Class I, Level A recommendation. These guideline recommendations are based on multiple randomized clinical trials. In addition, the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C Genotype 1 regardless of fibrosis stage. Additionally, treatment of patients before they progress to cirrhosis is advantageous. Based on evidence of safety and efficacy in the published literature, and clinical guidelines, Harvoni is medically necessary for 12 weeks in this case. Final Result:  Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and ribavirin for treatment of his hepatitis C virus genotype 2.  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 AASLD and IDSA guidelines, treatment naive genotype 2 patients should be treated with Sovaldi and ribavirin for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 2 regardless of fibrosis stage (Zeuzem, et al; Lawitz, et al; Jacobson, et al). The AASLD/IDSA guidelines do not recommend any other regimens for ribavirin-eligible genotype 2 patients. The guidelines also cite data showing increased survival with earlier treatment (Jezequel, et al). For these reasons, the requested treatment with Sovaldi and ribavirin is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition.  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 enrollee is requesting reimbursement for CPAP machine. According to the record, the patient has a history of recurrent laryngeal papilloma. He underwent a flexible scope laryngoscopy and the physician noted the enrollee had worn a continuous positive airway pressure (CPAP) mask for sleep apnea for many years with resolution of daytime somnolence; however, the mask began improperly fitting and leaking. Results of the original study are not provided. His body mass index is 28.6 and his neck circumference 17.5 inches.  A home sleep test was performed indicating mild sleep disordered breathing and obstructive sleep apnea (OSA). He had three minutes of total study time below 88% oxygenation. His physician prescribed CPAP supplies for the diagnosis of OSA to replace the old one that stopped working after approximately 10 years. The enrollees obstructive sleep apnea was noted to benefit with continuous positive airway pressure (CPAP) therapy. Although the home sleep study showed mild obstructive sleep apnea, a berlin questionnaire administered prior to study was positive in categories one and two indicating high risk of obstructive sleep apnea. The sensitivity of this test regarding probability of having sleep apnea is 86 percent. CPAP therapy has been shown to result in significant reduction in daytime sleepiness in OSA patients. Thus, the enrollees ESS score of four, not showing significant daytime sleepiness, is not unexpected since the enrollee was on CPAP for many years. Neck circumference (NC) is a clinical feature that may be associated with OSA. The enrollees neck circumference of 17.5 suggests a high probability of OSA. As well, oxygen desaturation index of 9.7/hour indicates the enrollee desaturates in his sleep. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in sleep medicine, pulmonary medicine, critical care medicine and internal 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old female enrollee has requested acupuncture treatments for the treatment of her hormonal imbalance. Findings:  The physician reviewer found that the condition of hormonal imbalance relates to changes in the levels of estrogen and progesterone (Goroll and Mulley). An imbalance can result in allergy symptoms, depression, endometriosis, fibrocystic breasts, hair loss, facial hair growth, headaches, low sex drive, osteoporosis, premenstrual syndrome, incontinence, uterine fibroids, weight gain, water retention, bloating and dry skin. The documentation indicates that the patient also had issues related to premenstrual syndrome. Based on the submitted documentation, the only previous treatment she received was oral contraceptives. Per Fauci and colleagues, there are multiple accepted treatments for the patients condition, which include treatment trials with antidepressants (SSRIs), NSAIDs, diuretics, oral contraceptives and Depo-Provera. There has also been reported benefit from phytoestrogens and herbal remedies as well as supplementation with calcium, magnesium, Vitamin B6 and Vitamin E. Acupuncture is not an accepted standard therapy in this setting. While there is peer-reviewed evidence demonstrating the efficacy of acupuncture for the treatment of certain conditions such as chronic osteoarthritis and nausea and vomiting associated with chemotherapy, the use of acupuncture for the treatment of hormonal imbalance and/or premenstrual syndrome has not been shown to be effective.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old female enrollee has requested a breast ultrasound of the right/left breast for evaluation of her abnormal mammogram. Findings:  Two physician reviewers found that the submitted documentation and relevant literature fails to support the requested diagnostic procedure in this clinical setting. Bilateral automated whole breast ultrasound is not considered a standard medical therapy. Moreover, the medical literature cited above does not show a significant difference between whole breast ultrasound and hand-held examinations. Thus, the request for whole breast ultrasound of the right/left breast is not likely to be more beneficial than other modalities for the evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 24-year-old male with a reported weight loss of over 100 pounds 4 years ago. There is no reference to what his weight was four years ago, but he weighed 227 pounds at age 14 and now weighs 155 pounds. The patient complained of a discharge from the umbilicus with a foul odor and itching. His primary care provider (PCP) indicated the umbilicus was infected and prescribed an unspecified cream for belly button. The cream was presumably a topical antibiotic. The patient was referred to a general surgeon who noted an over 80 pound weight loss and recommended a plastic surgery consultation. The patients PCP requested authorization for a plastic surgery referral, which was denied by the Health Plan for lack of medical necessity.Two 5x7 photos are enclosed which do not demonstrate a pannus resting below the symphysis pubis or a chronically infected umbilicus.  Additionally, there are no records of office visits demonstrating active physician involvement in treating the infected umbilicus or clearly documenting the condition of the belly button and noting the medicines that have been tried and failed to control the patients symptoms of odor, burning and itching.  In summary, the clinical indications do not demonstrate that the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 31-year-old female enrollee requested authorization and coverage of orthognathic surgery for treatment of Mandibular Hypoplasia.  The health plan denied the enrollees request indicating that the requested surgery is not medically necessary.One oral surgeon 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: Overturned

A 45-year-old female enrollee requested authorization and coverage for a CT scan of her sinuses for the treatment of a nasal obstruction which causes significant snoring and difficulty breathing.  The health plan has denied this request indicating that a CT scan of the sinuses is not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the Health Plans denial on the basis that the requested CT scan is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

The enrollee requested reimbursement for genetic testing, DecisionDX-Melanoma. The enrollee has cutaneous melanoma. The provider recommended DecisionDX-Melanoma genetic testing to direct this enrollees treatment, risk for recurrence, surveillance and follow-up. Literature reports routine molecular testing, including gene expression profiling, for predictive purposes, is discouraged until better use criteria are defined. The application of molecular information for clinical management, such as sentinel lymph node eligibility, follow-up, and/or therapeutic choice, is not recommended outside of a clinical study or trial. The use of this testing is not supported by scientifically based guidelines of national medical research or governmental agencies. Additionally, based on the results of the original biopsy and clinical findings, this testing would not be of value in treatment planning for this enrollee.Final Result: The reviewer determined that the requested service was not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: The reviewer are board certified in dermatology 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: Upheld

A 52-year-old female enrollee has requested for a knee brace for treatment of the enrollee, who is status post anterior cruciate ligament repair. Findings:  The physician reviewer found that Wright and colleagues review of the literature, 12 randomized controlled studies noted no evidence that pain, range of motion, graft stability or protection from subsequent injury were affected by brace use. All told, postoperative bracing is not likely to change the clinical outcome after anterior cruciate ligament reconstruction.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Zoll LifeVest. The records provided for review document that this patient has a potentially reversible cardiomyopathy due to rapid atrial fibrillation. Her left ventricle ejection fraction (LVEF) was low and she has symptoms of congestive heart failure (CHF), which support that she is at higher risk for sudden cardiac death. However, she does not require a permanent implantable cardioverter defibrillator (ICD) until cardioverted to normal sinus rhythm and treated with medical therapy. During this treatment period, the patients ventricular function may recover and eliminate the need for a permanent defibrillator. Given the patients increased risk of sudden cardiac death and the possibility of improvement of left ventricle function with medical therapy, the use of the LifeVest was reasonable based on published guidelines. Given this support, the Zoll LifeVest was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the Zoll LifeVest was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400-100 mg, one tablet daily for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 2b. 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, based on clinical trials including ASTRAL-1 and ASTRAL-2 trials for Epclusa, which showed superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. 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 52-year-old female enrollee has requested an MRI of the cervical spine for evaluation of her neck pain.  Findings:  The physician reviewer found that this patient had not had any history of malignancy, abnormal laboratory values, neurologic or radicular symptoms, or any significant trauma. Additionally, there is no indication that the patient has had x-rays to evaluate her neck pain prior to the request for evaluation with MRI. According to the American College of Radiology imaging guidelines, patients with chronic neck pain should initially undergo five-view radiographic imaging and if there are no neurologic signs or symptoms further imaging is not needed (Daffner, et al.) Further, in the setting of neck pain, MRI of the cervical spine is acceptable when all of the following criteria are met: neck pain lasting longer than six weeks, no red flags and there is no response to conservative management. Based upon the information provided, this patient does not meet the above criteria, as there is a lack of evidence that conservative management has been attempted or plain x-rays have been obtained. Therefore, the Health Plans denial was appropriate and should be upheld.