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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Victoza (3 pens/30 day supply).Liraglutide (Victoza) is widely used for the treatment of type 2 diabetes mellitus. Researchers have noted that pharmacodynamic studies show multiple beneficial actions with liraglutide, including improved fasting and postprandial glycaemic control (mediated by increased insulin and reduced glucagon levels and minor delays in gastric emptying), reduced appetite and energy intake, and effects on postprandial lipid profiles. They have noted that the effects of liraglutide on insulin and glucagon secretion are glucose dependent, and hence the risk of hypoglycaemia is low. Researchers conducted a trial and concluded that liraglutide significantly improved glycaemic control compared to placebo in patients with type 2 diabetes, insufficiently controlled with sodium-glucose cotransporter-2 inhibitors (SGLT2is) with or without metformin, with no unexpected safety findings. Cardiovascular studies have also shown beneficial results in patients with diabetes type 2 treated with liraglutide.In this case, the patient has type 2 diabetes that has been treated with metformin, liraglutide (Victoza) and Lantus insulin from at least 2017 (3 years). The patient and her doctor report prior treatment with other GLP-1 receptor analogs, with historically reported side effects and adverse reactions. The patient has responded to well to Victoza and has been on this medication for many years. There is no medical basis in the submitted documentation to subject the patient to change at this time to another GLP-1 medication that could give her an adverse effect and adversely affect her diabetes control. Accordingly, the requested medication Victoza (3 pens/30 day supply) is medically necessary to treat the patients medical condition.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 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

A 36-year-old female enrollee, who is status post gastric bypass with a subsequent weight loss of over 100 pounds, has requested authorization and coverage for bilateral thigh lift.Findings:  The physician reviewer found that there is no medical documentation of on-going infections in the thigh skin folds and the photographs do not suggest cellulitis, ulcerations or rashes. There is no evidence of frequent office visits to a primary care provider or dermatologist for the management of clinically significant dermatologic problems that have either not responded to topical therapy or despite an initial response, have recurred and caused significant functional impairment.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a three-year-old male with a history of limited expressive language, poor play and very impaired social development are requesting authorization for early childhood partial hospitalization services.Reviewers Findings:  The reviewing physician found that the submitted clinical information indicates the patient was making progress with treatment, but progress was not yet maximized.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 56-year-old woman with a several-year history of depression. The patients provider notes the patient had a positive response to individual counseling. It has been recommended that the patient receive ten weekly sessions of individual counseling. The Health Plan indicates additional individual therapy is not medically indicated.The submitted records demonstrate the patient has clearly benefited from ongoing psychotherapy. Her psychiatrist, while providing pharmacology intervention, feels continued individual therapy is medically necessary. The patients therapy sessions are well documented and clearly show ongoing benefit. It is clear from the submitted records that psychotherapy has been instrumental in preventing relapse and rehospitalization. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The requested ten weekly sessions of individual psychotherapy should be authorized. At the end of the ten-week period, the patient should be reevaluated to determine whether additional individual psychotherapy should be authorized.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 32-year-old female who has the typical symptoms of macromastia and no known comorbidities.  She has been evaluated by her primary care physician (PCP), and his office notes document symptoms since October 2005, though the patient describes progressively worsening symptoms for two years. Strengthening and weight loss have not improved her condition. Her bra size is reported as 36G, and photographs show deep bra strap grooving.  The patient has requested authorization and coverage for a plastic surgery consultation for consideration of bilateral reduction mammoplasty. The Health Plan has denied her request citing a lack of medical necessity.Evaluation for a breast reduction is medically necessary for this patient. Her complaints of shoulder, neck and back pain and bra strap grooving are typical for this diagnosis.  Photographs confirm deep bra strap grooves. Her symptoms have not improved with exercise and weight loss, which is not surprising, as symptomatic macromastia is a mechanical problem and conservative treatments have been shown to be ineffective for this condition. As the authors of the Collins and Kerrigan paper conclude, non-operative treatments are unlikely to improve her pain, and surgery provides the only bona fide chance for symptomatic relief. This patient requires evaluation for a breast reduction. Her PCP has examined her, ordered appropriate x-rays and ruled out any comorbid conditions.  Plastic surgeons are the specialists with the most knowledge and experience in treating macromastia.  A trial of conservative therapy is not warranted based on the medical literature, which contains no studies that show that conservative therapy is of any value for this condition. Therefore, I have determined the requested consultation is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for an ultraviolet light home therapy device. There are many ways to treat chronic plaque psoriasis if topical steroids are not an option due to contraindication, ineffectiveness, or side effects. Phototherapy is one way to treat psoriasis and can be safe and efficacious. There are also several other standard therapies such as medications including methotrexate and Humira. In this case, there is no evidence to suggest that a home phototherapy unit will be more beneficial than any other standard psoriasis treatment. According to the documentation, the patient does not have a serious physical condition that prevents him from going to in-office phototherapy. Given these findings, the requested ultraviolet light home therapy device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested ultraviolet light home therapy device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the requested device 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:  One reviewer is board certified in dermatology and is actively practicing. One Reviewer is board certified in dermatology and is actively practicing.  One Reviewer is board certified in dermatology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old female enrollee requested authorization and coverage of orthotripsy for the treatment of plantar fasciitis.  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 upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee has requested an increased dose of Oxycontin for treatment of his pain management secondary to Crohns disease.  Findings:  The physician reviewer found that Baron and colleagues reported that high dose opioids may contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opioids for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. In addition, high dose opioids may cause adverse outcomes as documented by Ballantyne and Mao. The authors discussed studies demonstrating that prolonged use of high dose opioids may induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. It is therefore, in the best interest of the patient to wean the Oxycontin or establish an opioid holiday.
Appeal type: Experimental/Investigational
Decision: Overturned

A 64-year-old female enrollee has requested for magnetic resonance imaging (MRI) of the right breast for evaluation of her medical condition.   Findings:  Two physician reviewers found that this patient has right breast pain with a persistent area of palpable asymmetric fullness. She has undergone conventional imaging (mammogram and ultrasound) which showed no suspicious findings. A breast MRI is utilized to evaluate suspicious palpable abnormalities when conventional imaging studies are normal. The American Society of Breast Surgeons state that a breast MRI is medically appropriate, for the further evaluation of suspicious clinical findings or imaging results which remain indeterminate after complete mammographic and sonographic evaluations combined with a thorough physical examination. Enriquez and Listinsky advocate for a breast MRI in patients with, a compelling clinical presentation with negative or equivocal imaging results. Swayampakula and colleagues also recommend breast MRI for patients with inconclusive findings on physical examination, ultrasound and mammogram. It is well-documented in the peer-reviewed literature that conventional breast imaging does not detect all breast cancers.  A breast MRI used as an adjunct to conventional breast imaging can diagnose breast cancers that are mammographically occult.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee has requested familial adenomatous polyposis (FAP) genetic testing for evaluation of her colon polyps.  Findings:  Two physician reviewers found that familial adenomatous polyposis (FAP) genetic testing is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Per the criteria the individual should have greater than 20 adenomatous colonic polyps during lifetime or first or second degree relations should have a history of FAP syndrome, or first or second degree relatives should have a history of FAP gene mutation. The patient had a colonoscopy which revealed approximately 12 polyps, but only 4 polyps were tubular adenomas. In this patients case, only one tubular adenoma was in the cecum, and one in transverse colon and the other two were in the distal colon, descending and sigmoid colon. The patient does not fall in the category of attenuated familial adenomatous polyposis syndrome. Therefore, genetic testing to detect mutation in FAP gene is not clinically indicated as the patient does not meet the criteria. For the reasons provided above, the requested FAP genetic testing is not likely to be more beneficial for treatment of the patients medical condition than other modalities.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old male enrollee has requested Supartz injections for treatment of his knee pain. Findings:  The physician reviewer found that the efficacy of viscosupplementation in the treatment of osteoarthritis of the knee has been accepted for years, with reduction in pain and improvement in function, as noted by Bellamy and colleagues. Some benefit has been found in a repeat course of injections, if there was a satisfactory response to the first course, per Waddell and colleagues. It has been suggested that multiple repeat courses of therapy might be of value, but additional well-designed, randomized, controlled trials of high methodological quality are needed to resolve the uncertainties remaining, as noted by Wang and colleagues. Clinical practice guidelines suggest that there be a progressive approach to treatment, utilizing pharmacological as well as non-pharmacological treatments, including the use of non-steroidal anti-inflammatory medications, acetaminophen, and other analgesics, and the use of steroid injections. In this case, there is no documentation of the use of treatments or medications other than an injection, presumably steroids. Physical therapy was suggested, but there is no documentation of the particulars of treatment or the results.  Further, there is no history of ulcer or gastrointestinal problem which would influence the selection of medications. All told, the submitted documentation does not demonstrate that the Supartz injections provided were clinically indicated.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old female enrollee requested magnetic resonance imaging (MRI) of the left knee for medical evaluation of the enrollees left knee pain.  Findings:  The physician reviewer found this patient sustained substantial blunt force trauma to the knee and continues to have significant pain.  Although plain films were normal, bone contusion or even microfracture is not excluded and the knee would be best evaluated by MRI.  The requested MRI of the left knee would allow for evaluation of possible internal derangement.  The requested diagnostic procedure will allow for evaluation of bone pathology which might not be evident on plain radiographs.  Although the requirement of conservative therapy prior to MRI is usually reasonable, in a case of blunt force mechanical trauma and persistent pain, imaging evaluation prior to physical therapy is medically reasonable.  All told, the requested MRI of the left knee is medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for implantation of a cranial nerve neurostimulator for treatment of the enrollees obstructive sleep apnea. Findings:  The physician reviewer found that there is sufficient support in the medical literature for the requested services in this clinical setting. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. After decades of trials demonstrating proof of concept of hypoglossal nerve stimulation in animal and human subjects, the three and four year results of a large multicenter, prospective trial were published in January 2016 and February 2017. The STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of write out (OSA). This trial has demonstrated the hypoglossal nerve stimulator to be safe and effective in a small subset of patients with obstructive sleep apnea (OSA) who have failed CPAP. With a BMI of 29, AHI of 49 and nonconcentric airway collapse at the velum, this patient meets the criteria. He has failed CPAP, which is the gold standard treatment for OSA and is at risk for untoward cardiac sequelae of untreated OSA. Moreover, this procedure is U.S. Food and Drug Administration approved and recognized by the American Academy of Otolaryngology Head and Neck Surgery. It is also recognized by the International Sleep Surgery Society. Therefore, implantation with a cranial nerve neurostimulator is likely to be more effective than the standard options available for treatment of this patients medical condition. Final Result: Two of three reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in otolaryngology 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 otolaryngology 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 otolaryngology 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 breast tomosynthesis for evaluation of the enrollees medical condition. Findings: Two physician reviewers found that the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Patients who have dense breasts benefit most from breast tomosynthesis which has the ability to separate out the overlapping structures with the possibility of demonstrating an otherwise occult tumor. In this case, the patient has heterogeneously dense breasts. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. All told, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two 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: Three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested for Ambien and Lunesta for treatment of her insomnia. Findings:  The physician reviewer found that the documentation fails to establish the medical necessity of the requested medications. This patient has a significant history of overuse of the requested medications.  American Psychiatric Association guidelines indicate that managing sleep is an important aspect of bipolar disorder.  This patient is on a sedating medication for this condition.  There are numerous alternatives, either as adjuncts or as mood stabilizing agents, which are less likely to be abused. Current evidence-based practice standards do not support the use of the requested medications in this clinical situation.   All told, Ambien and Lunesta are not medically indicated for the treatment of this patient.