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

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested coverage for inpatient psychiatric services from 2/15/19  2/19/19. The Health Plan denied this request as not medically necessary. A review of the records indicates the enrollee with a history of Bipolar Disorder, Alcohol Use Disorder, Depression, and Body Dysmorphia Disorder presented to the hospital with reports of worsening depressive symptoms, suicidal ideation, and seven days of alcohol use.  He had reports of a past suicide attempt.  He was drinking many shots of alcohol per day for the week prior to admission.  He had reports of impaired functioning including missing work. Medications included Fluoxetine and Olanzapine.  He lived with his family. He was admitted to the inpatient mental health level of care and received medication management, group and individual therapy, and was followed by Psychiatry, Social Work and Occupational Therapy. Review of the records indicates this was a high risk patient due to his initial clinical presentation of having worsened depression with suicidal plans to overdose or cut his wrists and past reported suicide attempt.  According to the medical literature, patients with past suicide attempts are at high risk for suicide and past suicide attempts are the most reliable predictors of suicide. These patients may require more time in the hospital to better assess risk of suicide because sometimes they do not tell the truth regarding suicidal thoughts in order to leave the hospital. This enrollee was considered a high risk patient and was a candidate for inpatient acute hospital treatment as he had continued depression, had two suicidal plans on admission and a past reported suicide attempt. Notes after admission reported that his depression was still significant and was rated an 8 out of 10. He was isolative, guarded, withdrawn, and depressed. He was not interacting with peers and was still depressed. In addition to the suicidal plans, he was drinking heavily so he was also at risk for life threatening withdrawal.  The inpatient level of care was appropriate for one day.  However, as of the third day notes indicate that he denied suicidal ideation, had improved mood and was compliant with medications. A note the next day reported that he felt better and his depression was less at 3 out of 10 and he still denied suicidal ideation.  He was discharged one day later. Thus, the inpatient level of care was not appropriate for the subsequent two days.Final Result: The reviewer determined that the requested service was medically necessary for one of the days, but not medically necessary for the subsequent days for treatment of the enrollees medical condition. Therefore, the health plans denial should be partially overturned. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Wegovy. Medical literatures note that obesity remains a continuing global health concern, as it is associated with increased risk of numerous chronic diseases, including type 2 diabetes, hypertension, and cardiovascular disease. The authors further note that while lifestyle modification is recommended as the cornerstone of obesity management, as many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss, there are currently multiple pharmacologic therapies which are available for weight management. Researchers report that glucagon-like peptide-1 (GLP-1) analogs, such as Wegovy, improve glycemic control, reduce body weight, and decrease cardiovascular risk. Researcher notes that GLP-1 receptor agonists have an established efficacy and safety profile. Given that current medical literature supports the use of the Wegovy in promoting weight loss and the low likelihood of health risks associated with this medication, the requested medication is medically indicated. Therefore, Wegovy is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes, 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Promacta for treatment of her medical condition.  Findings: The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication.   Immune thrombocytopenic purpura (ITP) is an autoimmune disorder where platelets are recognized by bodys immune system and eliminated. Platelet counts can decrease to very dangerous and life threatening levels. The standard course of therapy includes intravenous immunoglobulin (IVIG), steroids, rituximab, and anti-D. There are two newly U.S. Food and Drug Administration (FDA) approved thrombopoietin receptor agonists for ITP, Nplate (romiplostim) and Promacta (eltrombopag). Nplate is indicated for the treatment of ITP patients who have had an insufficient response to corticosteroids, immunoglobulin, or splenectomy. Additionally, Nplate should be used only in patients with ITP whose degree of thrombocytopenia and clinical condition increase the risk for bleeding. Eltrombopag has a similar indication. Per the prescribing information, Promatcta is indicated for thrombocytopenia in adult patients with ITP who have had an insufficient response to corticosteroids, immunoglobulins, or splenectomy. Thus far, this patient has not exhausted standard options such as IVIG, splenectomy, or rituximab. In the absence of failure of standard treatment options, the requested medication has not been established as medically necessary.   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 medical oncology and hematology 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 three-year-old male who was diagnosed with asthma and prescribed Xopenex in November 2004. The patient had been treated with Xopenex in the past, which was stated to be effective. When the patients parents attempted to fill the prescription for Xopenex provided by the treating physician, they were provided with albuterol as an alternative. The parents have stated that albuterol has not been as effective as Xopenex for treatment of the patients symptoms. The Health Plan indicates that the effectiveness of albuterol and Xopenex is comparable, and that Xopenex is not approved for children under age six.The clinical records document the patient suffers from reactive airway disease, as he wheezes and coughs with infections, requiring the use of nebulized medication. The patient had been previously treated with Xopenex with beneficial results. Although the physician records do not indicate a failed trial with albuterol, the patients parents state they attempted treatment with albuterol with poor results. Although Xopenex has not been formally approved for use in children under six years of age, its use in very young children is rapidly becoming the community standard of care, as there have been recent studies which demonstrate the superiority of its efficacy over albuterol for these patients. Further advantages of Xopenex over Albuterol include: 1. Xopenex is a pure isomer with no pro-inflammatory property; 2. Xopenex is easier to utilize requiring no mixing with solution; 3. Xopenex is longer lasting than albuterol (6-8 hrs. vs. 3-4 hrs.). The records confirm that the patient required repeated treatments with albuterol vs. a longer lasting effect with Xopenex; and 4. Xopenex has been shown to prevent frequent emergency room visits and hospitalizations.Based upon the information set forth above, 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: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested for intravenous ceftriaxone (Rocephin) for treatment of her Lyme disease.   Findings:  Three physician reviewers found that the patient has no indication for the use of intravenous antibiotics. Furthermore, extended or repeat courses of antibiotics have not been shown in double-blind, placebo-controlled trials in peer-reviewed journals to be efficacious in the treatment of Lyme disease. All told, there is inadequate evidence to support the use of antibiotics in this setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation therapy. The records provided for review document that this patient has a history of Gleason 3+3=6 prostate cancer. The patients treatment plan includes moderately hypofractionated (28 fraction) intensity modulated protons directed at the prostate and seminal vesicles with use of hydrogel. There is a lack of medical evidence demonstrating that treatment with proton therapy is associated with a clinical benefit compared to photon therapy in the treatment of patients with prostate cancer. In addition, proton therapy has not been validated in a comparative randomized study to conventional treatment with photons. A recent multi-institutional analysis of 1,850 patients with low or intermediate risk prostate cancer compared groups receiving hypofractionated radiation proton therapy and intensity modulated radiation therapy (IMRT) with photons (Vapiwala, et al.). The authors reported no significant difference in gastrointestinal or genitourinary toxicities or disease control between the two modalities. A position statement from the American Society of Radiation Oncology (ASTRO) noted that, Proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry. The ASTRO position statement indicated that the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. Similarly, the National Comprehensive Cancer Network (NCCN) guidelines do not recommend proton therapy in lieu of photons using IMRT technique. For these reasons, the requested proton beam radiation therapy is not medically necessary for treatment of this patient. 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 radiation oncology 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 reimbursement for FoundationOne genetic tests.Findings:  Two of the three physician reviewers found Molecular diagnostic studies in non-small cell lung cancer are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network guidelines strongly advise broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. In sum, FoundationOne genetic tests were likely to have been of greater benefit than other methods of evaluating this patient. 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 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: Experimental/Investigational
Decision: Upheld

A 42-year-old female enrollee requested authorization and coverage of gastric bypass surgery with duodenal switch for the treatment of obesity related comorbid conditions including gastroesophageal reflux disease, stress incontinence, and osteoarthritis.  The health plan denied the enrollees request indicating that the requested procedure is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  All three physician reviewers concluded that the requested gastric bypass surgery with duodenal switch is not likely to be more beneficial for treatment of the enrollees morbid obesity than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested authorization and coverage for continuous passive motion (CPM) machine. Colleagues reported their findings suggested that CPM reduces arthrofibrosis requiring manipulation under anesthesia in pediatric patients after anterior cruciate ligament (ACL) reconstruction. The authors noted that future studies might better define the clinical utility of CPM in rehabilitation after this type of surgery in pediatric patients. Colleagues concluded that CPM has beneficial effects on pain reduction during the first two postoperative days, on knee flexion during the first to the sixth postoperative weeks, and on swelling between the fourth and the sixth postoperative weeks. The authors cautioned that the risk-of-bias scores did not support a high level of evidence for their findings. Overall, the current evidence-based medical literature provides limited support for the use of CPM following cruciate ligament reconstruction. However, this patients case represents an exception. The physician reviewer found that the records document that the patient presented with a chronic isolated left knee posterior cruciate ligament (PCL) injury, medial meniscus tear, and chronic posterior instability. She failed long-term reasonable and comprehensive conservative treatment. She underwent left knee PCL reconstruction with allograft, double bundle technique, and medial meniscus tear debridement. Considering the combination of intraarticular procedures and inherent deep dissection, the patient is at increased risk of severe disruptive adhesions. The CPM will provide ongoing movement and reduce the risk of the patient developing adhesions and range of motion deficits (Bram, et al.). Therefore, the request for a CPM machine is medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested device is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Cimzia for treatment of the enrollees rheumatoid arthritis. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the requested medication. The American College of Rheumatology guidelines for the treatment of rheumatoid arthritis suggest that the first-line therapy for this condition includes biological disease-modifying antirheumatic drugs such as Plaquenil or sulfasalazine alone or in combination with steroids. These therapies are recommended prior to anti-tumor necrosis factor therapy, such as Cimzia. Prednisone and Plaquenil have been considered safe for nursing patients with rheumatoid arthritis. The medical evidence does not support the requested medication in this clinical setting. Therefore, Cimzia is 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 internal medicine with sub-specialty certification 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Euflexxa injections in both knees (HCPCS code J7323).An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, there is a history of good extended response to prior viscosupplementation. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being total knee arthroplasties. Therefore, Euflexxa injections in both knees (HCPCS code J7323) are medically necessary for treatment of the 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bronchial thermoplasty for treatment of the enrollees severe persistent asthma.  Findings:  The physician reviewer found that There is data supporting the benefits of bronchial thermoplasty for selected patients. In this patients case, his asthma symptoms are atypical, being strictly exertional dyspnea and without otherwise having a demonstrable trigger. Per the records, his methacholine is positive, and the immunoglobulin E (IgE) level and exhaled nitric oxide levels are elevated, pointing to some manner of allergic disease. This may account for his dyspnea. The documentation indicated that the patient was started on Xolair. However, the medical records do not reflect the effects of Xolair. Additionally, the records do not document follow-up with an allergist and possibly starting immunotherapy. Until these are documented as attempted and unsuccessful, there is not a role for bronchial thermoplasty at this time.  In sum, bronchial thermoplasty is not likely to be more effective than other treatment modalities in this patients case. Final Result: Two of 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in pulmonary 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in pulmonary 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in pulmonary 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.