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

A 29-year-old male has requested Ambien CR 25mg (12.5mg x 2 tablets per day) and Adderall XR 75mg (25mg x 3 capsules per day for treatment of his attention deficit/hyperactivity disorder and insomnia.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantities.  In this patients case, the dosage of these medications exceeds the recommended limits established by the United States Food and Drug Administration.  The patient weighs 270 pounds and reportedly requires two Ambien CR tablets to sleep as well as high-dose, long-acting stimulant for his attention deficit/hyperactivity disorder due to a 4-hour to 5-hour duration of effect of his medication.  There is a lack of well-developed studies in the peer-reviewed literature that supports treatment with Adderall XR at a dose of 75mg daily.  The fact that a common side effect of stimulant medication is insomnia supports the notion that the current dosing of Adderall XR may be generating the need for the high-dose Ambien.  Additionally, there is a lack of well-developed studies in the peer-reviewed literature that demonstrates both superiority and safety of Ambien CR 25mg (12.5mg x 2 tablets per day).  In this case, the specific outcomes of previous systematic medication trials and non-medication therapies, such as cognitive behavioral therapy for insomnia, are unknown.  In the absence of evidence-based literature supporting this particular regimen, the requested medication quantities are not medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Intracept procedure. Although there are conservative nonsurgical treatments for chronic low back pain, in certain refractory patient populations, there are limited options for highly effective and sustained relief. This patient presents with a history of chronic low back pain without radiculopathy for at least 18 months. The provider reported that the patient has tried a number of modalities to improve his pain without sustained success. The provider noted concern about chronic use of non-steroidal anti-inflammatory drugs (NSAIDs) and opioid dependence. The patient previously underwent a facet rhizotomy with reported improvement, indicating that at least some of his pain syndrome appears to be facet-mediated. However, the provider did not report the extent of improvement or whether repeated injections were performed. The records lack recent MRI findings to support an indication for surgical intervention. Specifically, there is no recent report of substantial degenerative changes at other levels (Modic changes). In addition, there is no documentation of dynamic x-rays to rule out instability as a potential pain generator. Moreover, there is a paucity of data in the peer-reviewed medical literature establishing a clinical role for the Intracept procedure for the treatment of chronic low back pain. Based on the records provided for review, the requested Intercept procedure is not 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 requested Intercept procedure 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 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: Physician reviewers 1, 2, and 3 are board certified in neurological surgery 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: Experimental/Investigational
Decision: Overturned

A 43-year-old male has requested Rituximab (Rituxan) injections for treatment of his multiple sclerosis.  Findings:  Two physician reviewers found that the patient has refractory multiple sclerosis, and has been resistant to multiple first line therapies, including: copaxone, interferon, tysabri, gilenya, IVIG and solumedrol. Despite these therapies, the patients symptoms and MRI findings have demonstrated a progression in his disease. Given the patients disease progression, the patients provider recommended a trial of Rituximab (Rituxan). Although Rituximab is not a first line therapy for multiple sclerosis, there is very good literature supporting its use for this condition. Rituximab has been found to be effective in the treatment of multiple sclerosis, as an add-on therapy (Naismith, et al.). In a phase I clinical trial, patients were followed for a total of 72 weeks and received two courses of Rituximab six months apart. The authors reported no serious adverse events with the use of this medication (Bar-Or, et al.).  The use of a second-line therapy, such as Rituximab, is reasonable and appropriate in this case, as the patient has not responded adequately to the first-line therapies.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier once daily for 12 weeks for treatment of the enrollees hepatitis C virus. Findings: The physician reviewer has found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1b patients should be treated with regimens including Zepatier for 12 weeks. These guideline recommendations are based on clinical trial results showing a 99% cure rate. The patient has had negative drug testing, and has received education about treatment of hepatitis C with Zepatier. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier for 12 weeks is medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested chiropractic treatment for her primary immune deficiency syndrome.  Findings:  The physician reviewer found that the records suggest that the treatment was for maintenance as this patient has had ongoing chiropractic treatment since last year in 2012. This patient continues to return with exacerbations of her pain. According to the American Chiropractic Association (ACA), this patient received palliative care. The treatment notes do not document any physical examination and re-examination as required, or any condition that warrants ongoing chiropractic care. All told, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 71-year-old male enrollee requested authorization and coverage of  surgical resection of the left lobe of the liver for the treatment of liver cancer.  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 overturned the health plans denial on the basis that the requested surgery is  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old male enrollee has requested  for residential treatment services for treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that review of the submitted clinical information demonstrates that the patient was not motivated for treatment and there was no expectation of his benefiting from continued treatment. He was not at serious risk and he was not responding to the treatment plan. His treatment plan did not motivate him.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested reimbursement for bilateral breast explant with full capsulectomy and bilateral superior pedicle breast lift.  Researchers noted that although silicone implants are now routinely used in breast surgery they have previously been the subject of controversy. The authors also concluded that there is a paucity of research to establish long-term outcomes. Medical literature notes that the evidence remains inconclusive about any association between silicone gel implants and long-term health outcomes. This patient has been experiencing seizures and she has expressed concern that her condition is related to her silicone gel breast implants. The current data does not support a causal relationship between the presence of silicone gel implants and this patients symptoms. Thus, removal of silicone gel breast implants and capsulectomies were not medically necessary. In addition, the bilateral superior pedicle breast lift was performed to tighten the breast skin and compensate for removal of the breast implants. All told, the bilateral breast explant with full capsulectomy and bilateral superior pedicle breast lift was not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his hepatitis C.  Findings:  The physician reviewer 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 should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load. The guidelines state that patients with HIV co-infection are at high risk for complications and should be prioritized for treatment.  The guidelines recommend that treatment-naive genotype 4 patients should be treated with Harvoni for 12 weeks.  The American Association for the Study of Liver Diseases and the Infectious Diseases Society of America guidelines also recommend Technivie/ribavirin for 12 weeks.  However, the guidelines specifically recommend against the use of Technivie/ribavirin with darunavir, which the patient takes for HIV.  All told, Harvoni is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for robotic assisted total knee arthroplasty of the left knee. The records provided for review document that this patient presents with left knee osteoarthrosis. The patient is planned to undergo total knee replacement with use of robotic assistance. The current standard of care for total knee arthroplasty includes use of traditional instrumentation and techniques. Excellent long-term functional and patient reported outcomes have resulted with these methods as substantiated in many high-level published reports. Short- and medium-term follow-up studies of robotic assisted total knee arthroplasty have shown slight improvements over traditional methods in terms of component alignment, but this has not translated to improved functional and patient reported outcomes. Given the current absence of robotic long-term outcomes, superiority over traditional total knee arthroplasty has not yet been established. Accordingly, the requested robotic assisted total knee arthroplasty of the left knee is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested robotic assisted total knee arthroplasty of the left knee  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 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: Physician reviewer 1 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery 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 has requested chiropractic services for the treatment of her neck and back pain. Findings:  The physician reviewer found that the medical records lack specificity as to progression of care, diagnosis, clinical impressions and management.  There is evidence of x-rays, but no documentation of the impressions of those studies.  The records do not indicate functional gain, consistency of progression, percent of recovery or return to normal function.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a positron emission tomography (PET) with computed tomography (CT) for attenuation. PET/CT is the preferred imaging test to evaluate a patient with a history of multiple areas of tumor involving the abdomen and pelvis including the peritoneum in the setting of prior surgery. The therapy this patient has received in the past requires a scan showing metabolic activity in all areas of interest in order to assess the degree of residual tumor. The measurement of the standardized uptake value (SUV) on PET/CT increases the accuracy with which to evaluate tumor stability or progression. Since the PET scan will be fused with a CT at the same time, the patient will not need a conventional CT scan. The PET/CT will be compared to prior similar studies, which will make the assessment of tumor activity more reliable than with conventional CT alone. Given these findings, the requested PET scan with CT for attenuation is supported as medically necessary for further evaluation and treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopic or laparoscopic assisted hysterectomy. Findings:  The physician reviewer found that, although hysterectomy may be the ultimate management, there is increased morbidity associated with this procedure and it is not a default or first-line management for patients frustrated with irregular menses. Hysterectomy is reserved for patients who have undergone an appropriate work-up and have an indication for the procedure. As noted by the American College of Obstetricians and Gynecologists (ACOG), the work-up for this patient would typically include pelvic exam, current Pap smear, evaluation of the uterus-cavity either by pelvic ultrasound, hysteroscopy or sonohysterogram, and evaluation of the endometrial lining either by endometrial biopsy or dilation and curettage. Overall, there is a lack of documentation of this patients work-up to support an indication for hysterectomy. There is no current Pap smear noted or record of the evaluation of the uterus and endometrium available. The patients pelvic exam describes an abnormal bimanual exam, suggesting a bulky non-specifically enlarged uterus. There is discussion of an endometrial biopsy in the past, but no documentation is provided for review. Further, the records do not indicate whether endometrial ablative procedures have been considered, or that the patient is a poor candidate or has other contraindications to the procedure. The notes indicate that the patient in the past had been treated with over the counter pills and progesterone to control cycles, which are no longer effective. However, two other options within the hormonal management realm include longer term progestins such as Depo-Provera or a progestin containing intrauterine device (IUD). All told, this patients records do not support the medical necessity of the requested laparoscopic or laparoscopic assisted hysterectomy. Final Result: The reviewer determined that the requested surgery 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 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: Upheld

A 23-year-old male enrollee has requested Norco for treatment of his pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Norco is not medically necessary for treatment of the patients pain.  The 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 treatment.  The current medical evidence does not support the requested medication in this clinical setting.   Baron and McDonald reported that high-dose opiates might contribute to pain sensitization.  High-dose opiates are more likely to cause adverse outcomes.  The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  All told, Norco is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for bilateral MRI of the breast. This patient underwent diagnostic mammography with breast ultrasound for clinical findings and dense breasts with architectural distortion. Since the diagnostic mammogram was inconclusive, the provider recommended a breast MRI. Inconclusive mammography is one of the recognized indications for breast MRI. Breast MRI has been shown to be more sensitive than mammography and was indicated to assist in identification of a lesion for biopsy. With a complicated physical examination and inconclusive mammogram, MRI was appropriate in guiding clinical recommendations for this patient. Therefore, the bilateral MRI of the breasts was likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation 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 obstetrics and gynecology 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

A 60-year-old female enrollee has requested for continued skilled nursing care for treatment of her low back pain. Findings:  The physician reviewer found that the patient was a fall risk and had not reached her maximal potential, which is the goal of rehabilitation. Since she was at supervision level, she was at fall risk.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old male enrollee has requested a tissue rearrangement procedure for the treatment of the enrollees scalp scar. Findings:  The physician reviewer found that in 1998, the California legislature passed AB1621 (Figueroa), which added Section 1367.63 to the Health and Safety Code. Section of 1367.63 of the Health and Safety Code requires Health Plans to cover reconstructive surgery, which is defined as `surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease, in order to improve function or to create a normal appearance, to the extent possible. Cosmetic surgery is defined as surgery `performed to alter or reshape normal structures of the body in order to improve appearance`. Health Plans are not required to provide coverage for cosmetic procedures.  This patients scalp alopecia is an abnormal structure caused by a congenital defect.  The surgery is reconstructive to normalize appearance as it will provide the patient with a complete head of hair rather than enhance an already normal appearance.
Appeal type: Medical Necessity
Decision: Upheld

A 38-year-old female enrollee has requested for Humira for treatment of her arthritis. Findings:  The physician reviewer found that there is a lack of support for the use of Humira for the treatment of systemic lupus erythematosus-related arthritis. .