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

Nature of Statutory Criteria/Case Summary: An enrollee has requested continued skilled nursing services for treatment of the enrollees medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Hip fractures are conditions that are known to substantially impact functional performance, and negatively impact both short-term and long-term health-related quality of life.  In this case, the patient also has a history of multiple sclerosis with mild impairments in her mobility and self-care abilities at baseline, further complicating her convalescence.  She underwent a hip replacement and has been undergoing inpatient rehabilitative care.  She has made functional improvements, but has plateaued at requiring stand by assistance for safety for most of her self-care and household level mobility.  She requires assistance for her lower body dressing.  While further gains may be expected going forward, the rate of this progress is not expected to be expedient or predictable, and her rehabilitative needs can be addressed at a less intensive level of care than an inpatient skilled nursing facility, such as a custodial level facility or the home with custodial level assistance and community-based therapy services.  There are no indications that she has been requiring skilled nursing care.  There are no documented impairments that would preclude her from propelling a manual wheelchair for household distances if she fatigues during the course of the day due to deconditioning and her multiple sclerosis.  All told, continued skilled nursing services were not and are not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not and 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 physical medicine and rehabilitation 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 23-year-old male enrollee has requested the medication Xifaxan for treatment of his irritable bowel syndrome. Findings:  The physician reviewer found that although the Food and Drug Administrations approval for this medication is for travelers diarrhea, there are many peer-reviewed articles supporting the usefulness of Xifaxan in the setting of IBS. A study by Pimentel, et. al. concluded Xifaxan improves IBS symptoms for up to 10 weeks after discontinuation of therapy. Another study by Sharara, et. al. showed that Xifaxan is safe and effective for abdominal bloating and flatulence in IBS patients. All told, there was sufficient evidence of the efficacy of Xifaxan in this setting to justify its use by this patient.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for a custom right knee orthosis.The submitted documentation does not support that the requested orthosis is medically necessary. The documentation does not reveal physical exam evidence of a deformity of the knee or leg that interferes with fitting, disproportionate size of thigh and calf, or minimal muscle mass upon which to suspend an orthosis. The submitted physician examination notes do not reveal objective evidence of right knee instability such as varus/valgus or drawer signs. The documentation includes conflicting notations, as one progress note records that the patient has no known allergies while also noting that the patient reports that he has an allergy to material in knee braces. The physical exam reveals no evidence of significant leg edema, and the documentation does not identify any material to which the patient reports an allergy. In addition, the patient's stature does not establish medical necessity for a custom brace, as a prefabricated brace with extensions for tall patients and extra-large straps for obese patients on a prefabricated brace are alternative options. The documentation also does not reveal objective evidence of an inability to ambulate with an appropriately fitted prefabricated knee orthosis. Under these circumstances, the requested custom right knee orthosis is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested orthosis 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 physical medicine and rehabilitation, with subspecialty certification in neuromuscular 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype DX Prostate Cancer Assay (CPT 0047U). Findings:  The physician reviewer found that Current National Comprehensive Cancer Network (NCCN) guidelines support testing with Oncotype DX post-biopsy for patients with low or favorable intermediate risk prostate cancer. This patient presented with Gleason score 3+4 prostate cancer with involvement in one of nine cores biopsied. His provider recommended evaluation with a tumor-based assay, the Oncotype DX Prostate Cancer Assay. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of NCCN risk groups (Cuzick, et al.; Sinnott, et al.). Patients with clinically localized disease may consider the use of tumor-based molecular assays to assist in treatment decision making consistent with the NCCN recommendations. Tumor-based molecular assays, such as the Oncotype DX Prostate Cancer Assay are considered within the standard of care in this patients clinical setting. Therefore, the Oncotype DX Prostate Cancer Assay (CPT 0047U) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the Oncotype DX Prostate Cancer Assay (CPT 0047U) was likely to be more beneficial for evaluation of the patients medical 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 internal medicine with subspecialty 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:   An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C.  Findings:  Three physician reviewers found that the proposed treatment is considered the standard of care for the treatment of the patients with hepatitis C, genotype 1 infection.  Per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic hepatitis C should be treated regardless of fibrosis score.  Per the guidelines, the medical evidence supports treatment of all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  In this case, Harvoni for 12 weeks is medically indicated for the treatment of this patient.  Final Result: Three reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are 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 56-year-old female has requested physical therapy (pelvic floor, levator, coccygeal mobilization and strengthening) for treatment of her pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy in this patients case.  This patient has a history of low back pain, and she has undergone a number of treatments for her problem, none of which have provided her any sustained relief of her pain.  Currently, she has been receiving vaginal floor physical therapy.  However, based on the information provided by the patient and her providers, she has not had any sustained improvement in her symptoms.  She has requested an ongoing approval for continuation of this vaginal muscle therapy, with no defined therapeutic conclusion.  The information provided by the physical therapist is sparse, with no clear documentation of her pathology, progress, and therapeutic goals.  It does appear that she received some benefit from pelvic trigger point injections, but the incremental improvement provided by the physical therapy is undocumented.  Although pelvic myofascial problems can contribute to pelvic pain syndromes, it is unclear that she has chronic pelvic pain, as the description of her pain is more related to her low back.  The current medical evidence recommends reevaluation of patients who do not respond to pelvic floor physical therapy after 8 to 10 weeks, possibly with additional testing or radiographic imaging.  In this case, the patient underwent treatments at a frequency of two to three times per week for months, with minimal improvement.  All told, the requested physical therapy (pelvic floor, levator, coccygeal mobilization and strengthening) is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee has requested Cymbalta for treatment of her complex regional pain syndrome.  Findings:  The physician reviewer found that Duloxetine (Cymbalta) is approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic musculoskeletal pain and for major depression. Arnold and colleagues conducted a randomized controlled trial and reported Cymbalta was an effective and safe treatment for the treatment of fibromyalgia. According to this patients medical records, she has been on name brand Cymbalta and has been doing well. The records indicate that when the patient was switched from the brand name Cymbalta to a generic, the generic tablet was larger and difficult for her to swallow. Given this patients success with Cymbalta for at least five years, the requested medication is supported as medically necessary for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting reimbursement for inpatient hospitalization. The enrollee has a history of depression and eating disorder. She was admitted to the inpatient psychiatric level of care after presenting to the emergency department for a progressive decline in function. The enrollees composite LOCUS score corresponds with Level IV; however, due to the enrollees score in the dimension of Functional Status, Level V care is warranted. The inpatient level of care is beneficial to this enrollees condition. Final Result: The reviewer determined that the requested service was medically necessary for the treatment of the enrollees medical condition. 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: Experimental/Investigational
Decision: Overturned

A 30-year-old female enrollee requested authorization and coverage of prolotherapy. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees myofascial pain syndrome.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three  physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for (1) Gammagard (immune globulin) infusion administered on 2/12/21 and (2) Gammagard (immune globulin) infusions every 4 weeks. In this case, the patient has a history of recent sinopulmonary infections in the setting of low IgG levels and pneumococcal antibody levels. In this clinical setting, given the patients history of infections in the setting of abnormal laboratory values and diagnosis of specific antibody deficiency, the services at issue were and are medically indicated. Therefore, (1) Gammagard (immune globulin) infusion administered on 2/12/21 and (2) Gammagard (immune globulin) infusions every 4 weeks were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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 internal medicine and in allergy and immunology 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 inpatient psychiatric treatment for treatment of his behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Throughout the course of this patients inpatient hospitalization, his medications were adjusted, which he tolerated without difficulty, but his psychotic symptoms remained unchanged.  Olanzapine was discontinued and clozapine was started and was eventually titrated up to 350mg.  The patient was given transcranial magnetic stimulation treatments.   However, his delusions and paranoia remained.  The medical records do not indicate that continuing stay at this level of care would have benefited this patient who presented with a psychotic illness that had proven refractory to multiple modalities of treatment.  Based upon the records submitted for review, his treatment had become custodial in nature.  All told, inpatient psychiatric treatment was not and is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female has requested a colonoscopy with biopsy for evaluation of her symptoms.  Findings:  The physician reviewer found that the patients symptom of self-limited bleeding was likely to be of distal colorectal origin. Therefore, the original plan for a sigmoidoscopy was appropriate and the standard of care in this setting would be to perform a repeat sigmoidoscopy with optimal preparation. This patient does have a family history of colon cancer, however her most recent colonoscopy was negative. The guidelines published in the peer reviewed medical literature regarding colonoscopy screening do not support the need for this patient to undergo a formal colonoscopy at this time.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for subcutaneous implantable cardioverter defibrillator (ICD). Findings:  Three physician reviewers found that based on traditional risk factors, this patient does not meet the criteria for ICD placement for primary prevention of sudden cardiac arrest. The records do not indicate a family history of sudden cardiac arrest or a maximal wall thickness greater than 3.0 cm. However, based on the totality of the medical records, specifically the cardiac magnetic resonance imaging, which demonstrated a greater than 25% left ventricle scar burden, the patient is at significant risk for sudden cardiac arrest even though he has not met the traditional criteria for prophylactic ICD placement.  The emerging risk factor of extensive myocardial scarring exceeding 15% should be strongly considered. In this case, standard therapy would be watchful waiting and/or medical therapy, which have not been found to be as protective as ICD placement. Accordingly, subcutaneous ICD placement is likely to be of greater benefit for the treatment of the patients medical condition than the available standard therapy. Final Results: 2 of 3 reviewers determined that the requested device is 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are 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 male enrollee requested authorization and coverage of continued physical therapy for the treatment of cervical thoracic myofascial pain syndrome.  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 51-year-old female enrollee has requested for adult psychiatric acute inpatient services for treatment of her behavioral health issues.  Findings:  The physician reviewer found that the patient had no active suicidal ideation, no obvious delusional thoughts, and a moderately depressed mood.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Mavyret 100-40 mg, three tablets daily, for eight weeks. According to the most 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1a patients should be treated with Mavyret, three tablets daily, for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 mg, three tablets daily, for eight weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested home health physical therapy for the treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Per present evidence-based clinical practice guidelines for the management of chronic low back pain, the focus of treatment should be patient education, self-care, common analgesics, exercise and remaining active.  Formal physical therapy may be needed in some cases for instituting an appropriate exercise and independent modality program, but there is no necessity for a home based therapy program if a patient is able to attend an outpatient program.  The records in this case do not establish that the patient would be unable to perform an independent program or travel to outpatient therapy.  The records indicated normal lower strength, capacity to drive more than 1.5 hours, and capacity to walk at least half a mile.  Despite his ongoing symptoms, services such as formal therapeutic exercises, formal modalities and manual therapy in the setting of chronic low back pain, moreover, provide no proven marginal benefit on health or functional outcomes over independent exercise and self-administered palliative interventions such as massage using rollers, or passive palliative modalities such as local ice/heat.  All told, the requested home health physical therapy is not medically necessary for the 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 physical medicine and rehabilitation 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.