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

An enrollee has requested authorization and coverage for the medication Kineret 100 mg.Medical literature does not support that the requested medication is medically necessary at this time. The submitted documentation indicates that the patient has recurrent pericarditis. Glucocorticoid therapy should generally be avoided in patients with recurrent pericarditis due to side effects and the risk of increasing recurrences. There are no adequately controlled clinical trials that have evaluated the efficacy of Kineret as a steroid sparing agent in patients where steroids are administered. Accordingly, the medical literature does not support the use of Kineret to treat recurrent pericarditis at this time. Therefore, Kineret 100 mg is not medically necessary to treat the patients medical condition.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 internal medicine, with subspecialty certification in cardiovascular 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections every 12 weeks.Findings:  Two of the three physician reviewers found that the current medical evidence supports the requested services in this patients case. The records documented a history of at least 15 headache days per month. Botox injections are indicated in this clinical setting. Botox injections have been approved by the U.S. Food and Drug Administration for the treatment of chronic migraine. Based on the submitted clinical documentation, this patient is likely to benefit from Botox injections. Thus, Botox injections every 12 weeks are likely to be superior over other available treatment options. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in neurology 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: Upheld

A 60-year-old female enrollee has requested BRCA testing for evaluation of her risk for breast cancer given her family history of breast cancer in her mother and maternal grandmother.  Findings:  The physician reviewer found that screening for BRCA mutations is indicated in patients whose personal or family history predicts a high likelihood of finding one of these mutations. Identifying those who carry these mutations has clinical importance and requires special measures aimed at risk reduction. Well established guidelines identify patients in whom genetic screening is warranted. Based on this patients pedigree, according to established guidelines, BRCA testing is not recommended. This patient has one first-degree relative in her mother, and one second-degree relative in her maternal grandmother who had breast cancer. However, the advanced age at the time her mother and grandmother were diagnosed does not suggest BRCA carrier status. In addition, her familys ethnicity was not documented as Ashkenazi descent, which would be an indication for testing. All told, the requested testing is not supported as medically necessary for evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested the UroLift prostatic urethral lift procedure for treatment of his benign prostatic hyperplasia.  Findings:  Three physician reviewers found that the requested services are not likely to be more effective for this patient than other available options. There is a lack of medical literature supporting the requested services in this clinical setting. UroLift is still undergoing data collection for its role in different clinical situations and has not been shown to exceed the efficacy of standard treatment of benign prostatic hyperplasia (BPH) or decrease the long-term complications or recurrence rate. Therefore, given the lack of support in the peer-reviewed literature the UroLift prostatic urethral lift procedure has not been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the requested services are 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: All three reviewers are board certified in urology 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 59-year-old male enrollee requested authorization and coverage of Synvisc injections for the treatment of osteoarthritis of both knees.  The health plan denied the enrollees request indicating the requested injections are 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 injections are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genotype testing.Findings:  Three physician reviewers found that genetic testing was requested with the rationale being that the patient failed multiple neuropsychiatric medications, and has demonstrated sensitivity to others.  However, the medications tried and failed, and those she was sensitive to were not listed.  Genetic testing results would show if a patient is a normal responder of certain classes of medications, may be more or less likely to respond to certain medications, is at low risk of certain adverse events, at higher risk of others, or may have decreased activity of a certain enzyme activity.  Studies have shown that clinically useful predictors in genetic testing are scarce for antidepressant therapy, with results being inconsistent and only marginal clinical association between enzyme system variants and drug metabolism, efficacy, and tolerability in the treatment of depression.  The current evidence does not support the use of genotyping when choosing an antidepressant, and even less is understood about its use in the treatment of anxiety disorders.  Genetic testing lacks evidence-based research to show its effective use in guiding the clinician towards choosing a medication regimen.  Final Result: Three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in psychiatry 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: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of his hepatitis C virus. Three physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. In this case, the Health Plan has approved Viekira Pak which has been FDA approved for the treatment of patients with chronic active hepatitis C genotype 1 based upon clinical trials. Treatment with Viekira Pak is as safe and effective as Harvoni for genotype 1 patients. In this case, the documentation provided for review does not demonstrate the patient has contraindications to the use of Viekira Pak. As such the request for Harvoni is not medically necessary in this clinical setting. Final Result:  Three reviewers 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: One reviewer is board certified in gastroenterology and is actively practicing.  Two 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 gallium 68GA-dotatate positron emission tomography/computed tomography (DOTA-TOC PET/CT) scan for evaluation of the enrollees metastatic pancreatic neuroendocrine tumor.  Findings: The physician reviewer found that there is current data that gallium based scans such as the requested DOTA-TOC PET/CT are superior to conventional imaging including 18FDG-PET/CT in the evaluation of neuroendocrine tumors due to their molecular tagging. In several studies, the sensitivity and specificity of the gallium based scans have been remarkable. The challenge in this patients case, is the lack of appropriate serological markers, specifically Chromogranin and gastrin, which would be typically elevated in this type of tumor. The test requested is available at a limited number of facilities and ordinarily would not be medically necessary in the vast majority of patients. However, considering the unique circumstances of this case, the requested DOTA-TOC PET/CT is supported as medically necessary and appropriate for further evaluation and treatment of this patient.Final Result: The reviewer determined that requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 39-year-old woman who has psoriasis covering approximately 30% of her body surface area and has had the condition for at least 20 years. Appropriate topical therapies have been tried as well as UVA and cyclosporine; all have been ineffective. The patient has also been treated by a neurologist for recurrent diplopia and was advised that Enbrel is contraindicated because she may have demyelinating disorder. The patients dermatologist prescribed Raptiva and outlined the reasons why other medications are ineffective and/or contraindicated for her.  The Health Plan denied authorization for Raptiva based upon their determination that it is not medically necessary.The patient is of childbearing age and because the possibility of pregnancy exists methotrexate and Soriantane should be eliminated as alternatives to Raptiva. With regard to cyclosporine, the increased risk of serious side effects with long-term use should be considered in addition to the fact that it did not work well for this patient. Enbrel is contraindicated in patients with possible demyelinating disorders, as indicated by the neurologist. This is related to the effect of tissue necrosis factor (TNF) on such disorders. Enbrels method of action involves TNF.  Raptiva is the only appropriate and effective medication remaining for the treatment of this patients psoriasis.  Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization psychiatric level of care. The submitted documentation supports the medical necessity of the services at issue. This patient had a prominent addictive illness burden. He had an early age of onset and had a history of significant substance abuse as a young adult. His drug use led to health issues, family distrust and relationship distress. He had previously received treatment in at least the residential and outpatient settings. Per the records, the treatment in dispute successfully facilitated transition to less restrictive programming in the community. Considering the severity of this patients illness burden and his prior treatments, partial hospital services were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards. Additionally, the services at issue were reasonably expected to improve his condition and prevent a more serious episode of illness. Therefore, partial hospitalization psychiatric level of care was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue 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

The patient is a 42-year-old male who injured his knee while skiing and subsequently underwent arthroscopic ACL reconstruction. Postoperatively he utilized a CPM machine as prescribed by his orthopedic surgeon for approximately three weeks.  He is requesting reimbursement for the rental cost of the device. The Health Plan denied coverage based upon their determination that the CPM machine was not medically necessary following the patients surgery. A CPM machine is commonly prescribed by surgeons for postoperative rehabilitation following ACL reconstruction. Patient compliance appears to be high and many surgeons find that patients regain their range of motion faster and have better pain control with the device. The orthopedic community has recognized the benefit of early range of motion following this type of surgery and the use of the CPM machine postoperatively is medically appropriate. Therefore, I have determined the requested device is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computed tomography (CT) coronary calcification testing. Findings:  The physician reviewer found that Numerous clinical studies have demonstrated that coronary artery calcium scoring using ultrafast cardiac CT can add predictive value in assessing risk of coronary heart disease. In one study, a score of zero was associated with a coronary heart disease risk of 1-6%, while a coronary artery calcium score over 300 was associated with a risk of 13-26% (Budoff, et al.). However, the current clinical studies have not demonstrated that coronary artery calcium scoring adds value in clinical management of asymptomatic patients in whom risk factors are targeted. Mamudu and colleagues examined whether CT coronary calcium scoring in asymptomatic patients might have an effect on behavior modification, risk perception, and medication adherence. The authors found that although CT coronary calcium screening improved medication adherence, the impact of coronary artery calcium screening on behavioral and lifestyle factors, perception of coronary heart disease risk, and psychosocial effects was not statistically significant compared with baseline. Overall, there is insufficient support in the peer-reviewed literature demonstrating a significant benefit of CT of the heart with quantitative evaluation of coronary calcium in guiding optimal clinical management of this patient. Therefore, the requested CT coronary calcification testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the requested CT coronary calcification testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in cardiology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and clinical cardiac electrophysiology and is 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: Upheld

A 48-year-old female enrollee requested authorization and coverage for an increase in the  current prescription medication Amerge for the treatment of severe migraine headaches.  The health plan indicates that the requested increase in the patients prescription is not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested prescription amount increase is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 25-year-old female who had gastric bypass surgery in 2002. Her pre-bypass weight is not recorded. The records reflect a weight loss of 110 to 165 pounds with a weight in December 2005 of 195 pounds and a BMI of 30.5. One provider noted a target weight of 160 to 170 pounds. The patient does not want to wait to lose more weight because of the severity of her complaints. She complains of chronic skin infections, rashes, pimples and boils in the abdomen skin. She has constant skin irritation in the axilla from skin-on-skin rubbing and contact. She requests coverage for a panniculectomy, brachioplasty, breast reduction, thigh lift and buttocks lift. She has seen at least two plastic surgeons that agree with the panniculectomy, but want her to lose additional weight from her recorded 216 pounds in May 2005 and 220 pounds in June 2005. The patients personal notes and the notes of her health care providers all reflect symptoms from the significant weight loss. The patient has requested authorization and coverage for panniculectomy/abdominoplasty, brachioplasty, breast lift and reduction, thigh lift, and buttock lift.  The Health Plan denied the request based on a determination that the requested procedures are not medically necessary.The record provided for review included 20 pages of color photographs of the patient. They indeed show significant erythema in the groin creases, axillary region and under the breast folds, but no demonstratable skin irritation is seen in the lower back/buttocks regions. The treatment records do indicate that topical antifungal agents were prescribed, but the patients complaints continued to such a degree that she has indications for surgery as described in the position paper from ASPS.  It says in part Resection of redundant skin and fat folds is medically indicated if panniculitis or uncontrollable intertrigo is present. Chronic or recurrent skin infections may occur. A large overhanging pannus may cause lower back pain and interfere with ambulation and personal hygiene. It goes on to state, in female patients with ptotic breasts after massive weight loss, macromastia may be present and associated with postural backache, upper back, neck and shoulder pain. Intertrigo and related dermatitis may also be present. Reduction mammoplasty is indicated in these patients. Also, stated in the position paper is Resection of upper arm and thigh tissue is performed to improve the patients comfort and appearance. With the exception of the buttock lift, this patient has signs and symptoms sufficient to qualify all of the requested surgeries as reconstructive and not cosmetic in nature.Based upon the information set forth above, I have determined the majority of the requested procedures are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned with one exception (buttock lift).
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old female enrollee requested authorization and coverage of a power-operated vehicle. The Health Plan  denied the request indicating that the requested equipment is not medically necessary for the treatment of the enrollees chronic spastic paraplegia. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 26-year-old female enrollee has requested continued inpatient stay for the treatment of her behavioral health problems. Findings:  The physician reviewer found that this patient has a dense compendium of psychiatric problems and was particularly ill across all diagnoses. The severity of her struggles with food continued throughout her stay. Both the pharmacologic as well as psychotherapeutic approaches appear to have been sound. The medical documentation, inclusive of the aforementioned notes, points to the persistence of the patients morbidity throughout the hospitalization. Transfer to a less restrictive setting during the period at issue posed a significant likelihood of deterioration in functioning.