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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Relizorb cartridge. Relizorb cartridges are comprised of lipase immobilized onto polymeric carrier beads, which when placed in a feeding tube, release small amounts of lipase in steady dosing. Freedman and colleagues found that use of Relizorb was safe, well tolerated, and resulted in significantly increased levels of plasma omega-3 fatty acid concentrations, suggesting overall increased fat absorption. Stevens and colleagues found that enteral nutrition using Relizorb improved fatty acid abnormalities in patients with cystic fibrosis, and that Relizorb could have important long-term therapeutic benefits in patients with cystic fibrosis. In this case, the patient has cystic fibrosis and has established the efficacy of Relizorb based on improved post-feeding symptoms and increased body weight after starting on Relizorb. Maintaining a BMI above 20 is of critical importance as the patient is scheduled to undergo a pre-lung transplant evaluation. Therefore, the requested Relizorb cartridge 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 certifications in pulmonary disease and critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee has requested for Morphine Sulfate 700 mg/day and Norco for treatment of her reported chronic low back pain and peripheral neuropathy. Findings:  The physician reviewer found that there is no medical indication for the patients present dose requirements for Morphine Sulfate and Norco. Current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy (Fishman). If opiates are indicated, controlled release narcotics with close monitoring by a certified physician, primarily a board certified pain management specialist, is recommended. Presently any prescription narcotic medication exceeding the maximum recommended dose is only indicated for cancer pain patients with a terminal condition. The patient far exceeds the maximum recommended dose of Morphine Sulfate and Norco. Baron, et al. reported that high dose opioids might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opioids for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. High dose opioids may also cause adverse outcomes. As the patient requires more than the maximum recommended dose for opiates, this medication is not indicated. Ballantyne, et al. reported on studies indicating that prolonged use of high dose opioids may induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. Morphine Sulfate and Norco would be contradictory to providing safe and effective healthcare.
Appeal type: Experimental/Investigational
Decision: Upheld

A 48-year-old female enrollee has requested Intradiscal Electrothermal Therapy (IDET) for the treatment of her discogenic pain syndrome involving the L5-S1 disc. Findings:  Two physician reviewers found that the IDET procedure has been performed by a number of different practitioners and results are often varied.  There are no good long term studies documenting the efficacy of this treatment plan. This patient has degenerative disc disease, which is often treated conservatively with activity modification, anti-inflammatory medication, home exercises and long term weight loss. There is insufficient evidence that the requested IDET procedure will result in a superior clinical outcome over other treatment options in this setting.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female has requested coverage for a bilateral breast MRI for evaluation of her history of ductal carcinoma in situ.  Findings:  The physician reviewer found that the role of MRI in patients with a personal history of breast cancer and dense breast tissue on mammography is still evolving. According to the American Cancer Society Guidelines for Breast Screening with MRI as an Adjunct to Mammography, there is insufficient evidence to recommend for or against the use of MRI in women with a personal history of breast cancer, including DCIS. Further, while there is growing interest in the use of MRI for women with dense breast tissue, there is not enough long-term data to describe the utilization of MRI as a medically necessary modality for such individuals. To date, there is inadequate evidence demonstrating that the use of MRI as an adjunct to mammography for patients such as this patient results in improved clinical outcomes. Therefore, the requested bilateral breast MRI is not medically necessary in this particular setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Ingrezza 40 mg capsule. Tardive dyskinesia is a serious side effect from antipsychotic medications characterized by involuntary movements. Ingrezza was approved in 2017 for tardive dyskinesia. The patients tardive dyskinesia was noted in progress notes and in the providers letter. Based on the available clinical data, Ingrezza is approved for the patients condition and is reasonably expected to improve the patients condition. Moreover, there is no available alternative treatment at this time. As such, the requested Ingrezza 40 mg capsule is medically necessary for treatment of this patients medical condition. 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 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia services.  Findings:  The physician reviewer found that a screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The anesthesia services provided were not necessary for treatment of an emergency medical condition. With a laboring patient that is unable to have a vaginal delivery, a cesarean section is indicated. However, an emergency cesarean is reserved for those cases where the cesarean section needs to be performed as soon as possible, such as in the case of a cord prolapse or prolonged deceleration/bradycardia situation. In this case, the cesarean section was not emergent. Although anesthesia is indicated for a cesarean section, the services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the dates of service at issue. Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a tracheal shave for treatment of her gender dysphoria.  The physician reviewer found that review of the submitted clinical documentation demonstrates the patient is well-documented to have gender dysphoria; thus, her external anatomy should be more consistent with a female than a male. The submitted photographs depict a significantly prominent thyroid cartilage, which is more consistent with male anatomy. According to Capitan and colleagues, The principal differences between masculine and feminine facial features are related to the bone structure, although other important differentiating characteristics also exist, such as skin type, distribution of facial hair and fat, type of hair and hairline shape, the prominence of the thyroid cartilage or Adams apple, and differentiating characteristics in the soft tissues, among others. Furthermore, tracheal shave is considered part of the customary surgical treatment for male-to-female transition. In this patients case, medical necessity for the proposed tracheal shave has been adequately established by the submitted medical documentation and review of the patients photographs. Moreover, the proposed procedure is considered reconstructive surgery in this setting. In this case, the patient's prominent thyroid cartilage is considered abnormal for a female. This abnormal structure of the body is a result of the patients well-documented gender dysphoria. The proposed tracheal shave would help to create a more normal appearance for an individual of the female gender and is likely to provide more than minimal improvement in the patients appearance. As such, the requested tracheal shave meets criteria for reconstructive surgery.  Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition and reconstructive in nature. 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: Experimental/Investigational
Decision: Overturned

A fifty-two year-old female with osteoarthritis of the left hip is requesting authorization of a hip resurfacing arthroplasty.Reviewers Findings:After reviewing the request, 2 of the 3 physicians found the patient is an appropriate candidate for hip resurfacing arthroplasty.  The third physician found that there are no long-term prospective studies that show that hip resurfacing arthroplasty has clear benefit over traditional hip replacement procedures and the extent of the related risks is still unknown.  The reviewing physicians found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 43-year-old male enrollee has requested reimbursement Avastin injection for treatment of his choroidal neovascularization (CNV).  Findings:  Three physician reviewers found that there are numerous case series reports of improvement in vision and retinal structure with Avastin for treatment of idiopathic choroidal neovascularization. Moreover, in most diseases causing choroidal neovascularization, Avastin injection has been shown to be beneficial. Since idiopathic choroidal neovascularization is a rare condition, there are not likely to be any prospective studies evaluating this treatment. All told, the Avastin injection at issue was likely to have been more beneficial than any other available treatment for this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested open treatment of rib fractures requiring internal fixation for treatment of his rib fractures. Three physician reviewers found that the open treatment of rib fractures requiring internal fixation was likely to be more beneficial for treatment of the patients medical condition than available standard modalities. In this clinical setting, standard pain management was unsuccessful. Due to the patients uncontrolled pain, he underwent open treatment of rib fractures requiring internal fixation. With surgery, pain was controlled and pneumonia, the most frequent complication of rib fractures was avoided. In addition, the study by De Moya and colleagues confirms a significant reduction in the requirement for analgesia after surgical repair. In sum, the open treatment of rib fractures requiring internal fixation was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy given the patients uncontrolled pain, unstable chest wall, and worsening CT scan. Final Result: Three 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: One reviewer is board certified in general and thoracic surgery with sub-specialty certification in vascular surgery and is actively practicing. Two reviewers are board certified in general and thoracic surgery and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old male enrollee has requested occupational therapy sessions for the treatment of the enrollees autism. Findings:  The physician reviewer found that occupational therapy is an accepted treatment for children with autism. The Council of Children with Disabilities recommends occupational therapy for autistic children. It has been shown that deficits in neurological processing and sensory integration can be improved with occupational therapy. Based on the clinical evidence provided, the patient is an appropriate candidate for occupational therapy. The requested occupational therapy sessions are medically indicated and appropriate for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old male enrollee requested authorization and coverage of hyperbaric oxygen therapy and a PET scan for the treatment of multi-system impairment including toxic encephalopathy.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested a DEXA scan for evaluation of her osteopenia. Findings:  The physician reviewer found that the patient has had bone-density scans every year for the past three years. Her T-scores for the lumbar spine and hip have been fairly stable for all these years. The patient is not on steroid therapy and does not have a diagnosis of osteodystrophy or hyperparathyroidism. Every two years is a reasonable interval for follow up DEXA scans.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old male enrollee has requested for laboratory services (lipoprotein, blood; and high resolution fractionation and quantitation of lipoprotein) for evaluation of his medical condition.   Findings:  Two physician reviewers found that there is no convincing scientific evidence that the availability of the results of such testing can inform case management to any greater extent than measurement of those variables assessed in the usual standard screen of a patients lipid profile.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient detoxification services. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether inpatient detoxification services that were received were medically necessary for the treatment of the patients medical condition. ECT involves inducing a controlled seizure in a patient. Sedatives like clonazepam prevent seizures. A patient taking significant doses of sedatives can therefore not achieve the seizures needed for ECT to be successful. The American Society of Addiction Medicine (ASAM) criteria is the most widely used and comprehensive set of guideline for placement, continued stay and transfer/discharge of patients with addiction and co-occurring conditions. There are six dimensions of ASAM level 3.5 criteria. For acute intoxication and/or withdrawal potential, the patient reported experiencing withdrawal symptoms, including hallucinations. For biomedical conditions/complications, the patient was medically unstable given her hallucinations. For emotional/behavioral/cognitive conditions and complications, the patient was diagnosed with depression and was being treated with ECT. The patient also reported suicidal ideation and had a history of a previous suicide attempt. For readiness to change, the patient was noted to be apprehensive about detoxification. For relapse/continued use/continued problem potential, the patients relapse potential is high due to her depression. For recovery environment, the patient reported marital stress. Her husband did participate in her treatment. In this case, the patient was experiencing benzodiazepine withdrawal with hallucinations. This was a medical emergency requiring inpatient admission for detoxification. The medical evidence supports the services at issue in this clinical setting. Therefore, inpatient detoxification services that were received were medically necessary for the treatment of the patient. Final Result: The reviewer determined that the requested services were 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier tablets for 12 weeks for treatment of her chronic hepatitis C virus (HCV) genotype 1a. 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 recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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 Vumerity. Findings:  The physician reviewer found that Multiple sclerosis (MS) is a progressive immune disease affecting the central nervous system (CNS), causing neurological dysfunction and is one of the most common neurological immunologic diseases. Multifocal inflammation of the CNS characterizes the disease and causes impaired nerve conduction, which is what causes the many different symptoms of MS. MS is not a curable pathology; however, today there are several therapies that can manage the disease. The U.S. Food and Drug Administration approves the use of Vumerity for the treatment of relapsing forms of MS. In this case, the patient had been stable on Tecfidera but was experiencing adverse effects.  In this clinical setting, given that current medical literature supports the use of Vumerity in the treatment of MS, the requested medication is medically indicated. Therefore, Vumerity is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication 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 neurology with sub-specialty 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.