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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Zepatier for 12 weeks for treatment of the enrollees hepatitis C.  Findings:  The physician reviewer found that According to the 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. 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 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. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier for 12 weeks to treat hepatitis C is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty 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: Overturned

A 59-year-old female enrollee has requested proton beam radiation therapy, or in the alternative, intensity modulated radiation therapy (IMRT) for treatment of her thymic neuroendocrine cancer.  Findings:  Three physician reviewers found that there is evidence that aggressive treatment with chemotherapy, surgical resection, and post operative radiation therapy can produce long-term survival for patients with invasive thymic malignancies (Modh, et al). The target volume to be irradiated includes the neck and anterior mediastinum and part of the pericardium. IMRT enables the delivery of higher doses of radiation, which would increase the probability of disease control, while still limiting the dose to the surrounding esophagus, spinal cord, heart, and contralateral lung (Komaki and Gomez). Given the support in the medical literature, IMRT is likely to provide this patient with a more beneficial outcome than other available treatment options including proton beam radiation therapy. Thus, IMRT should be approved for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) Percocet 10 mg tablets, two tablets, three times per day, and (2) Norco, 10 mg tablets, one tablet, five times per day. On determining when to initiate or continue opioids for chronic pain, researchers report, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if the expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.  The Federation of State Medical Boards (FSMB) states, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. Further, the FSMB strongly recommends prescribers use opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. In this case, the patient has chronic pain secondary to paraplegia. He was completing a home exercise plan and there was no note of aberrant behavior or abnormal drug screens. The treating provider has determined that the benefits of opioid therapy outweigh potential risks. The records noted an unspecified allergy to Percocet and the patient reported that he preferred continued pain management with Norco over a buprenorphine patch. The records note that the patient has been on hydrocodone 10-325 mg, four tablets daily (120 tablets monthly), and the notes indicate that the treatment plan is to continue hydrocodone without changes. The patient has been referred to pain management. The submitted records do not indicate a plan for increasing opioid therapy or changing agents. In this clinical setting, (1) Percocet 10 mg tablets, two tablets, three times per day, and (2) Norco, 10 mg tablets, one tablet, five times per day are not medically necessary for the treatment of this patient. However, the treating physicians prescription of Norco, 10 mg tablets, one tablet, four times per day, are medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested a neuropsychology consultation for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation and medical literature fails to demonstrate the medical necessity of the requested services. The diagnosis of autism is usually made with specific instruments such as the Childhood Autism Rating Scale (CARS) or other standardized scales. The diagnostic testing for autism is typically performed by a psychologist, not a neuropsychologist.  After the diagnosis has been made, patients often are referred for applied behavior analysis (ABA) therapy to design a treatment program. In this case there is a lack of rationale provided for the requested neuropsychology consultation. For the reasons stated, the requested services are not medically necessary in this clinical setting.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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. In addition, the reviewer holds a current certification by a recognized American medical specialty board in the area or areas appropriate to the treatment under review.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 36 visits of cardiac rehabilitation. Findings: The physician reviewer found that based on the records provided, this patient has been diagnosed with coronary disease including recent coronary stent placement. In this circumstance of a recent coronary stent placement, cardiac rehabilitation is reasonable, appropriate and considered standard accepted practice in the medical community. There is support in the medical literature for cardiac rehabilitation after a coronary stent placement. The guidelines for patients who undergo percutaneous coronary intervention such as this patient also recommend formal cardiac rehabilitation. Therefore, 36 visits of cardiac rehabilitation has been established as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified internal medicine with sub-specialty 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the knee. The submitted documentation does not support the medical necessity of the requested service at this time. An MRI is the procedure of choice following negative knee x-rays to evaluate for possible internal derangement of the knee including suspected meniscal and/or medial collateral ligamentous disruption. Medial collateral ligamentous injuries on MRI have remarkable correlation with arthroscopic findings. In this case, the requesting provider has not documented any objective findings regarding the patients right knee. There are no specific maneuvers mentioned, such as anterior drawer sign, which would elevate the suspicion of internal derangement. There is also no documented point tenderness or impression of joint effusion. Under these circumstances, the requested MRI of the knee is not medically necessary to treat the patients medical condition at this time.Final Result: The reviewer determined that the requested service 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 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 22-year-old woman with a body mass index (BMI) of 47. She has comorbid conditions including hypertension. The patient has obtained psychiatric clearance for weight loss surgery. She wishes to undergo gastric bypass. The Health Plan has denied authorization for the requested procedure on the basis that it is not medically necessary for treatment of the patients morbid obesity.With a BMI of 47 and comorbid conditions, the patient meets accepted national medical necessity criteria for consideration of weight loss surgery. Roux-en-Y gastric bypass is medically indicated and medically necessary for treatment of this patients morbid obesity. Furthermore, scientific evidence does not show that structured weight management plans consisting of diet and exercise have been successful in the treatment of the morbidly obese. The study referenced above demonstrates that surgery has the best long-term outcome for the morbidly obese. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A male enrollee requested the LINX Reflux Management System for medical treatment of his severe gastroesophageal reflux disease (GERD).  Findings:  Two physician reviewers found that the requested procedure is a minimally invasive procedure, with support of safety and efficacy data in multiple studies. LINX procedure is a treatment option for patients with medically refractory GERD who have not yet progressed to end-stage reflux disease with associated complications. Given that the procedure is supported as safe and effective in patients with medically refractory GERD, it is clinically indicated for this patient. Therefore, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 63-year-old female enrollee has requested NovoTTF treatment for treatment of her meningioma. Findings:  Two physician reviewers found that meningiomas are brain tumors arising from the dura mater of the brain. They are typically slow growing and amenable to resection if pathologically classified as Grade I. However, Grade II and Grade III meningiomas have higher proliferative rates and are usually only partially resected. In 2011, the U.S. Food and Drug Administration approved the NovoTTF-100A device to deliver alternating electrical fields to treat recurrent glioblastoma multiforme (GBM). The approval was based on a randomized clinical study where 237 patients were treated with either NovoTTF versus best standard of care chemotherapy (including bevacizumab) (Stupp et al). There is also a case report of a long term survivor with recurrent GBM treated with NovoTTF (Villano et al). While there is limited data regarding the use of NovoTTF in the treatment of meningiomas, the device has FDA approval and based upon studies of its use in patients with GBM, it is appropriate for use in this patient who has exhausted standard treatment options. There is sufficient medical evidence to demonstrate the safety of this device and the off-label use for this patient. All told, there is adequate evidence demonstrating that the requested equipment is likely to be more beneficial for this patient than any available standard treatment modality.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old male enrollee requested authorization and coverage of left hip surface replacement. The Health Plan  denied the request indicating that the procedure is not medically necessary for treatment of the enrollees osteoarthritis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral Synvisc One injections. Findings:  The physician reviewer found that records document that this patient has a history of osteoarthritis of both knees for which viscosupplementation was successfully used in the past. Per the provider, the patient had previously received hyaluronic acid injections of both Synvisc One and Euflexxa with excellent results. Additional treatment has included physical therapy and other forms of conservative therapy without substantial improvement in symptoms. The provider has recommended repeat Synvisc One hyaluronic acid injections in both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of prior viscosupplementation with excellent results. Furthermore, the  other conservative treatments including physical therapy have not been effective. For these reasons, the requested bilateral Synvisc One injections are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic 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 49-year-old male enrollee has requested participation in a Phase III clinical trail at the University of Arkansas (UARK 2006-15) for treatment of his multiple myeloma. Findings:  Two physician reviewers found that the Phase III trial in question seeks to determine the `standard of care` for patients with multiple myeloma. All of the agents being used are indicated in the treatment of multiple myeloma, as is auto-transplant, which can be performed with curative intent for myeloma. Thus, no investigational or experimental agents or regimens are being evaluated. The patient has been determined to be an appropriate candidate for the trial and there do not appear to be any contraindications to his participation in the trial. The proposed clinical trial is evaluating the use of Velcade in the setting of debulking chemotherapy and tandem transplants. The use of high-dose chemotherapy and tandem transplantation is considered standard of care. Velcade is an FDA approved drug for the treatment of multiple myeloma. Given this patients age and prognosis, the proposed clinical trial is likely to be his best opportunity for disease control/eradication under these clinical circumstances. The proposed post-transplant randomization does not compromise the standard of care, and appears to be testing the role of a drug known to be active in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old male enrollee has requested Sovaldi and Olysio for treatment of his chronic hepatitis C. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication combination.  The standard of care for this patient is combination treatment with oral therapy consisting of two direct acting antiviral agents.  Per the current medical evidence, an interferon-free regimen has become the standard of care. This patient has advanced cirrhosis and therefore may be at risk for adverse outcomes with a delay in therapy.  He is at risk from decompensation with an interferon-based regimen.  There is sufficient support for the requested medication regimen in this clinical setting.  All told, Sovaldi and Olysio is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for monitored anesthesia care. The American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee noted that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. The authors recommended that, Anesthesia provideradministered sedation be considered for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise. The guidelines also noted, Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are ASA Class I, II, or III. Other candidates for minimal or moderate sedation include those with a history of previously successful procedures with moderate sedation and an expectation for moderate sedation as well as those undergoing a procedure that is expected to be uncomplicated or routine. In this case, the patient underwent a routine colonoscopy for suspected cecal mass. He did not have any significant heart, lung, kidney, or liver disease. There was no documentation of a history of alcohol or substance abuse. There was no detailed description of a history of difficulties with anesthesia or sedation in the submitted records. The patient had an ASA classification score of 1 and there was no evidence that he presented with a difficult airway. The literature does not support the use of monitored anesthesia care in a patient who does not have significant health conditions or airway concerns. Rather, the guidelines suggest there is high quality evidence to support the use of mild to moderate sedation in healthy, uncomplicated endoscopy procedures, such as in this case. Based on the current medical evidence, the service at issue was not medically indicated. Therefore, monitored anesthesia care was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain 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 62-year-old female enrollee has requested for chiropractic services for treatment of her left hip and low back pain. Findings:  The physician reviewer found that there is no clinically significant benefit with respect to analgesic, health or functional outcomes is expected with chiropractic therapy at this time based on the available clinical data.  There is no proven benefit of chiropractic treatment in the setting of chronic low back pain, chronic hip pain, or other musculoskeletal conditions.  In the review by Ernst and colleagues, the authors concluded that rigorous clinical trials have not demonstrated that chiropractic care is an effective intervention for pain control.  In 2008, Bronfort and colleagues did not note significant, sustained benefit to spinal manipulation and mobilization over other conservative management.  Although the patient remains symptomatic, the requested chiropractic therapy is not reasonably expected to provide significant clinical benefit beyond an ongoing physical therapy program or an independent exercise program.  All told, the requested chiropractic services are not medically indicated for the treatment of this patient.