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 Lantus Solostar insulin pens (U-100 insulin 100 units/mL (3 mL) subcutaneous insulin pen). This patient was diagnosed with type 1 diabetes mellitus at age 23. The patient is currently using Lantus Solostar insulin via pen, but he has used Lantus insulin via the vial in the past. Lantus is a once daily, long-acting insulin analog specifically designed to provide basal insulin requirements. There are multiple ways to inject insulin, such as with a vial and syringe or by using a pen device. Although newer, pen devices offer several benefits over a vial and syringe including more accurate dosing, which is associated with improved patient adherence. Given this support, the requested Lantus Solostar insulin pens (U-100 insulin 100 units/mL (3 mL) subcutaneous insulin pen) is medically necessary for 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 subspecialty certification in diabetes, endocrinology, and metabolism 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 laparoscopy implantation of the LINX Reflux Management System. Findings:  The physician reviewer found that the patient is with gastroesophageal reflux disease (GERD). The patient also has asthma per the patient history questionnaire.  The provider progress note reported a history of reflux, heartburn, and lower gastrointestinal bleeding. Abdominal ultrasound  was normal.  Endoscopy with biopsies showed gastritis but was otherwise normal.  Bravo pH study showed elevated acid exposure. Esophagram  was normal. Per the provider note, the patient does not want to be on medication for acid reflux long-term. The patient has requested authorization and coverage for the laparoscopic implantation of the LINX Reflux Management System for treatment of GERD. The Health Plan has denied the requested procedure as investigational for treatment of the patients GERD. There is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other standard surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined. Another best-evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Adverse events, such as erosion through the esophagus, have been reported since the U.S. Food and Drug Administrations (FDA) approval. A peer-reviewed journal published a letter stating that there are 11 reports of endoscopically-confirmed LINX erosion through the esophagus in the publically-accessible FDA adverse events database. Additionally, LINX is associated with severe dysphagia requiring endoscopic intervention. The available peer-reviewed literature does not definitively support the conclusion that LINX is likely to be more beneficial in this case than standard treatment of surgical fundoplication. Moreover, the American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. Based on the available literature and relevant clinical guidelines, laparoscopic implantation of the LINX Reflux Management System for treatment of this patients GERD is not likely to be more effective than other treatment options.Final Result: The reviewers determined that the requested procedure is 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  number 1,2 & 3 are 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

A 36-year-old male enrollee requested authorization and coverage of vein surgery. The Health Plan denied the request indicating that the procedure is not medically necessary for treatment of the enrollees varicose veins.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the clinical chemistry testing for evaluation of the enrollees Crohns disease.Findings:  Two physician reviewers found that based on the available documentation, there is no report that the patient developed a reaction to injections or that there was suspicion of an antibody to adalimumab. Further, there remains a lack of evidence for routine monitoring of drug levels in this clinical setting. While drug levels correlate inversely with disease activity and antibody levels at the group level, their role in the management of an individual patient remains unproven since the therapeutic or target drug level required to achieve clinical or endoscopic remission for any given patient remains unknown. Moreover, serum levels do not necessarily reflect tissue levels of drug. Finally, many patients experiencing a worsening of disease may do so via a mechanism unrelated to elevated tissue tumor necrosis factor (TNF) levels. Final Result: Two reviewers determined that the testing at issue was 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 internal medicine with sub-specialty certification in gastroenterology 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 epidurography and moderate sedation for treatment of the enrollees back pain. Findings: The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. Epidurogram is a diagnostic procedure performed to assess the structure of the epidural space in the spine. This procedure is done before epidural steroids are administered to ensure accurate delivery of this therapeutic material to the source of pain. Bosscher and Heavner evaluated the significance of diagnostic markers obtained through epiduroscopy by evaluating the accuracy of outcome prediction after treatment of epidural pathology using epiduroscopy. The study showed that lumbosacral epiduroscopy predicts outcome of treatment accurately in the majority of patients. The study suggests that information obtained through epiduroscopy may carry significant diagnostic and prognostic value in patients demonstrating radicular pain. In this case, the medical records lack documentation of a history and physical demonstrating radiculopathy requiring treatment with an epidurogram prior to epidural steroid injections. Therefore, the requested therapy for epidurography and moderate sedation has not been established as medically necessary for treatment of the patients medical condition.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 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 patient has requested authorization and coverage for partial mastectomy of right breast. Visscher and colleagues stated that sclerosing adenosis is a proliferative lesion that is commonly found in benign breast biopsies. The authors noted that, does not further stratify risk in women diagnosed with other forms of proliferative breast disease, either with or without atypia Findings: the physician reviewer found that the American Cancer Society states that, women with adenosis do not need treatment, but might be watched closely. Overall, the role of SA in breast carcinogenesis remains undefined. The literature suggests that SA may be a predictor of an increased risk of breast carcinoma in either breast, but it does not appear to be precancerous. Therefore, the requested partial mastectomy of the right breast is not medically necessary to treat this patients medical condition.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 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hydromorphone tabs 2 mg (70 tablets).  Findings:  The physician reviewer found that guidelines state that nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if 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) guidelines state that, 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. In this case, the patient was on chronic opioid therapy with his previous pain provider. During a consultation with his current provider on 8/21/20, the treatment recommendations included weaning off opioids and soma due to an unfavorable risk-to-benefit ratio. The provider recommended to focus the treatment plan on non-pharmacologic treatments including pain management injections and possible back surgery. On 9/4/20, the patient was seen and the treatment plan involved ordering an epidural steroid injection for the neck. The provider also concluded that chronic opioid therapy was not indicated but did offer an alternative in the form of suboxone which the patient declined. Based on the available documentation, the patients records do not support an indication for hydromorphone. Moreover, the providers assessment suggests that the benefits of continued opioid therapy do not outweigh the potential risks in this clinical setting. For these reasons, the requested hydromorphone tabs 2 mg (70 tablets) are not medically necessary for treatment of this patient.   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 anesthesiology with subspecialty certification in pain management 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

The patient is a 47-year-old woman with chronic neck pain and osteoarthritis. The patients comorbid conditions include epilepsy, depression, and hypertension. She is status post two posterior decompressions of the cervical spine and has chronic migraines. The patient has taken ibuprofen for temporomandibular related pain without relief. She has also been on Mobic. An esophagogastroduodenoscopy confirmed active ulcer disease. The patient is requesting coverage for Bextra for her pain. The Health Plan has denied the patients request on the basis that Bextra is not medically necessary for treatment of the patients chronic pain. Bextra is not medically necessary or indicated for treatment of the patients chronic pain. Review of the submitted medical records indicates an esophagogastroduodenoscopy confirmed active ulcer disease. In light of this finding, NSAIDs and COX2 inhibitors are contraindicated in this patient. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a four-year-old male enrollee requested authorization and coverage of continuing speech therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees autism.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee has requested continued acute hospital stay for her rehabilitation following laparoscopic cholecystectomy. Findings:  The physician reviewer found that the patient did not require continued acute hospitalization during the period at issue. The recommendation of discharge was appropriate. The patient was taking and tolerating her oral medications. She remained in the hospital because she refused to go home. Although she was not fully independent, below her baseline function, and potentially unsafe for discharge to her home, the level of care required was at a lower level of care than the hospital. As such, the patient did not require continued acute hospitalization.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her 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.  The guidelines report that patients with cirrhosis are highest priority for therapy.  Per the guidelines, genotype 1 patients with decompensated cirrhosis who have failed Sovaldi-based therapy should be treated with Harvoni and a low initial dose of ribavirin for 24 weeks. These guideline recommendations are based on multiple studies showing the effectiveness of Harvoni after Sovaldi failure. For these reasons, Harvoni 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: Overturned

A 67-year-old male enrollee has requested Botox injections for the treatment of his spasmodic dysphonia. Findings:  The physician reviewer found that the enrolle had a prior Botox injection that was successful in improving his vocal function. Botox injections have been the standard of care in the treatment of spasmodic dysphonia for at least the past 10 years. Although Botox is not FDA approved for this use, it is listed as an off-label application. In addition, the Health Plans Drug Coverage Criteria lists spasmodic dysphonia/laryngeal spasm under its indications for the use of Botulinum toxin type A, stating that prior authorization is not required.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for methadone 10 mg .Findings:  The physician reviewer found that : the records provided for review document that this patient has a history of multiple sclerosis, osteoporosis, and scoliosis, facet degeneration of the lumbar and lumbosacral regions, chronic lumbar radiculopathy, and back pain of lumbosacral region with sciatica. The documentation states that the patient is stable with her current regimen of methadone and is able to perform activities of daily living. The patient signed a medication contract ion the date of disputer. The patient has failed conservative therapy with first-line opioid medications. Further, the patient endorses benefit from the current regimen without side effects. Lastly, the patient is compliant with the current regimen and has a signed opioid contract in place. Therefore, the methadone 10 mg from date of dispute and forward was and is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the medication at issue was and 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 biopsy free tumor sequencing test for evaluation of the enrollees non-small cell lung cancer metastatic to the brain. Findings:  The physician reviewer found that to demonstrate the clinical utility of Guardant360 in this setting, prospective, randomized clinical trials are needed to compare the strategy of targeted treatment based on panel results with the standard of care. The available literature on its clinical utility consists of a small number of uncontrolled studies and nonrandomized controlled trials that use imperfect comparators. This evidence is not sufficient to make any conclusions as to its clinical utility. In the event a tissue biopsy cannot be obtained or is unsafe to conduct a plasma biopsy, using panel tests such as Guardant360 maybe useful to look for the actionable mutations. In this case, this patient had undergone tissue testing of the lung biopsy and metastatic brain tissue was tested for the recommended genomic tests. Guardant360 testing remains investigational in metastatic lung cancer and should only be used as part of a clinical trial when a tissue specimen is available and has been tested for genomic abnormalities. In addition, there is potential for harm if ineffective therapy is given based on test results, because there may be adverse effects of therapy in absence of a benefit. Final Result: The 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Remicade. Findings:  The physician reviewer found that this patients records document a history of rheumatoid arthritis with persistent disease symptoms despite treatment with multiple medical therapies. The patient is breastfeeding, and her provider has recommended treatment with Remicade. The American College of Rheumatology (ACR) guidelines do not require concomitant treatment of methotrexate with Remicade therapy for patients with rheumatoid arthritis. Earlier guidelines from the ACR state that methotrexate is not recommended for nursing mothers. The ACR does support treatment with Remicade in nursing mothers with rheumatoid arthritis. Given these findings, the requested Remicade is medically necessary for 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 rheumatology 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.