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 Enablex. Findings:  The physician reviewer found that anticholinergics are considered the mainstay of pharmacotherapy for overactive bladder. According to the American Urological Association (AUA), there are at least five anticholinergics which can be utilized to treat patients with overactive bladder. The records indicate that this patient has been treated with Enablex. The records provided for review document that this patient has had an adequate response to brand name Enablex, but not to its generic equivalent. 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 urology 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 medial branch radiofrequency ablation for treatment of his back pain. Findings:  Two physician reviewers found that the patient reportedly received bilateral diagnostic medial branch blocks on two different occasions, with significant temporary benefit.  He also is diagnosed with a radiculopathy for which transforaminal epidural steroid injections were provided and reportedly beneficial.  However, the records do not document reduction in the use of opioid analgesic medication despite the reported benefit.  The procedure note provided for the lumbar radiofrequency ablation describes localizing landmarks in the cervical spine and unspecified levels.  The documentation describes a cervical spine radiofrequency ablation being performed, which is not appropriate to treat lumbar spine pain.  The records were inconsistent, as the wrong part of the spine was noted in the procedure note.  There is a lack of support for the services at issue in this clinical setting.  Final Result: The reviewers determined that the services at issue were 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: Reviewers 21, 2, and 3 are board certified in physical medicine with sub-specialty certification in pain medicine and is 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 40-year-old male enrollee has requested physical therapy, three hours daily, Monday to Friday, for eight weeks for treatment of his status post gunshot wound. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The patient sustained a traumatic injury affecting the right-sided sacral nerve roots.  He has, in effect, a motor incomplete sacral spinal cord injury.  The majority of patients sustaining this type of injury regain functional ambulation at the community level.  Formal therapy and frequent physical activity play an important role in this process and in the general health and outcomes following this type of injury.  However, there is no medical necessity of formal therapy services at three hours per day, five days per week, on an outpatient basis in this case.  The patient has undergone inpatient rehabilitation and has been ambulating household distances independently with a walker.  He was independent with a home exercise program as of the time of discharge from inpatient rehabilitation.  There are no documented exercises that he cannot do independently or that could not be substituted with independent exercises.  No significant marginal improvement in clinical course or functional outcomes would be expected with the requested frequency and duration of therapies over a less intense schedule.  All told, physical therapy, three hours daily, Monday to Friday, for eight weeks, is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested interpersonal neurobiology therapy for treatment of the enrollees behavioral health condition.  The physician review found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Low intensity disruptive behavior is found in both healthy and disruptive preschoolers, which is defined as losing of the temper and low intensity property destruction.  It is not necessarily a predictor of school age conduct disorder.  There is a range of these behaviors which would be described as normal for this age group.  These same behaviors are described in her consultation, which are moderate in intensity, occurring once per day.  The documentation does not address how interpersonal neurobiology therapy materially differs from standard treatment modalities for a child this age with this intensity of disruptive behavior.  The records do not demonstrate that this patient requires interpersonal neurobiology therapy as opposed to traditional modalities.  All told, the requested interpersonal neurobiology therapy is not medically indicated 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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 43-year-old woman with a history of pelvic pain and abnormal bleeding. A pelvic sonogram diagnosed a fibroid uterus and a 2.7cm ovarian cyst. The patient was given Provera for a short time. She is requesting authorization and coverage for surgical intervention. The Health Plan indicates the requested surgery is not medically necessary for treatment of the patients medical condition.Standard of practice for the management of abnormal bleeding is to try hormone therapy for three to four months to control the bleeding and to dissolve the cyst. In addition, an endometrial biopsy should be performed to rule out endometrial cancer. Standard of practice for the management of pelvic pain is to determine if there is a gynecologic cause. A fibroid and a small cyst do not necessarily cause pelvic pain. If the above medications do not provide relief, then a laparoscopy may be indicated. If no gynecologic causes of pain are found, then genitorurinary (e.g., interstitial cystitis), gastrointestinal, and neuromuscular causes need to be considered with referral to the appropriate specialty.A trial of gonadotropin releasing hormone agonists might be considered to reduce amenorrhea, treat pain, and decrease the size of the fibroid. There is no medical indication for surgical removal of the cyst at this time. Furthermore, a myomectomy is not indicated in women of this age. Therefore, I have determined the requested surgery is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement the anterior optical coherence tomography (OCT). The anterior segment optical coherence tomography (OCT) used in this patients case was consistent with the recommendations in the current peer-reviewed medical literature. OCT is the standard of care for the evaluation of this patients condition and can provide information critical to treat her disease. In this case, anterior segment OCT was used to measure the patients cornea prior to keratoprosthesis surgery. Alternative modalities would not have provided comparable data and would have placed the patient at an increased risk. Accordingly, the anterior segment OCT was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found anterior OCT was likely to be more beneficial for evaluation of the patient's medical condition than any available standard therapy. Final Result: The reviewers determined that the anterior OCT was 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 ophthalmology 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Two physician reviewers found that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. The medical literature supports the services at issue in this clinical setting. Mammography plays a key role in early breast cancer detection. Single-institution studies have shown that adding tomosynthesis to mammography increases cancer detection and reduces false-positive results. As such, the addition of tomosynthesis to mammogram views has gained wide popularity among radiologists due to the associated decrease in callbacks and increased detection of small cancer particularly in patients with very dense or heterogeneously dense breast tissue as described in this patient. Therefore, the addition of breast tomosynthesis in this clinical setting was likely to be more beneficial for evaluation of this patient than any other technique. Final Result: Two reviewers determined that the diagnostic procedure at issue was 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: One reviewer is board certified in radiology and is actively practicing. Two reviewers are board certified in diagnostic radiology 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: Overturned

A 61-year-old female enrollee has requested a whole-body PET/CT scan for thr evaluation of her gastrointestinal stromal tumor (GIST). Findings:  The physician reviewer found that this patient has high-risk GIST and is status post surgical resection. She has had several prior PET/CT scans. It has been shown the PET/CT is slightly superior to PET and CT obtained separately and significantly better than CT alone in assessing tumor response to treatment. Research has found that for patients treated with imatinib (Avastin), PET/CT improves staging, accurately separates responders from non-responders in an early phase and is helpful during follow-up. With respect to GIST, there is sufficient evidence in the literature to establish the efficacy of PET/CT in disease detection and assessment of early response to treatment.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old female enrollee requested authorization and coverage of a PET scan for the diagnosing of breast cancer recurrence.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 overturned the health plans denial on the basis that the requested services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old male enrollee has requested Provigil for the treatment of his excessive sleepiness. Findings:  The physician reviewer found that the Food and Drug Administration (FDA) approved indications for use of Provigil include excessive sleepiness associated with narcolepsy, shift work sleep disorder and obstructive sleep apnea/hypopnea syndrome. The records provided for review demonstrate that this patient has obstructive sleep apnea (OSA) diagnosed via a sleep test. He does not get optimal effect from CPAP usage and is severely affected by sleepiness to a dangerous degree as he is noted to have fallen asleep while driving. It is not entirely clear how long this patient is able to tolerate CPAP on a given night as he has been reported to remove his mask in his sleep. This fact is not unusual and many patients (approximately 30-45%) are unable to fully tolerate and use CPAP for treatment of OSA. In the absence of an effective treatment for his OSA, it is necessary for the patient to be treated with an alerting medication such as Provigil to avoid dire consequences from his sleepiness. As is often observed in clinical practice, even fully controlled sleep apnea in a compliant patient may still result in residual sleepiness. Thus, the patient should be approved for use of Provigil in conjunction with the CPAP device for sleep apnea and related sleepiness.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Trintellix 30 mg (Trintellix 20 mg to use together with Trintellix 10 mg). Trintellix has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of major depressive disorder. This medication is typically dosed between 10 to 20 mg daily, and there are no appreciable studies of supra-therapeutic dosing in the peer-reviewed medical literature. In this patients, the current dose of Trintellix was achieved in late 2017 after a systematic titration targeting flat mood, poor motivation and lack of passion. By February 2018, the patients mood was improved, and he was consuming less alcohol. Per the records, the current medication dose appears to be both efficacious and well-tolerated, with no evidence of side effects or safety concerns. The treatment is optimizing functionality and minimizing the illness burden. There is sufficient support for the requested medication regimen in this patients case. Therefore, Trintellix 30 mg (Trintellix 20 mg to use together with Trintellix 10 mg) 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested skilled nursing facility rehabilitation for treatment of the enrollee, who is status post transcatheter aortic valve replacement.  The physician reviewer found that health outcomes following aortic valve replacement surgery are often significantly compromised.  Factors predictive of poor physical health outcomes following this surgery include significant heart failure, arthritis and living alone.  Nevertheless, cardiac rehabilitation programs are generally safe and effective following this type of surgery.  In this patients case, she would be a candidate for community-based (i.e., home or outpatient) rehabilitation to restore her conditioning and improve her function.  However, she does not require inpatient rehabilitation.  There are no indications in the available records that she requires inpatient level hospital care for rehabilitation, nursing or medical conditions.  Hospital level care to provide 24-hour supervision and custodial level assistance for self-care and mobility needs is not medically necessary.  This can be provided in a nursing home or other custodial level care facility.  All told, the requested skilled nursing facility rehabilitation is not medically indicated 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested Concerta (methylphenidate) for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that based on the documentation submitted for review, the requested medication is not medically necessary for treatment of the patients behavioral health conditions. The patient is currently receiving methylphenidate ER 36 mg, which is the generic form of Concerta. One of the formulary alternatives is methylphenidate sustained-release tablets, or generic Ritalin SR. The active ingredient of both these medications is methylphenidate.  The only difference between the two is the delivery system to make the medication extended release. In the case of the patients current medication, an osmotic delivery system is used. A different mechanism would be utilized for the proposed alternative medication. Switching from the current medication to another methylphenidate extended release is not likely to be difficult. Most likely, the patient could take 40 mg of the new medication instead of the current 36 mg and have a fairly similar medication effect. It should only take one or at most two visits to titrate to the effective dosage. In addition, the school year is almost over, so the timing would be appropriate to make the switch. Given the above, the requested medication is not medically necessary for treatment of the patients medical condition. 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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Epclusa 400-100mg, for 12 weeks. The submitted documentation supports the medical necessity of the requested medication. 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 nonliver-related conditions. In this case, the submitted medical records support that the patient has a positive diagnosis of hepatitis C, and the therapy recommended by the provider is one of four that is scored as a 1A recommendation by the AASLD/IDSA guidelines. Accordingly, Epclusa 400-100mg, for 12 weeks, is medically necessary for treatment of 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 a subspecialty certification in infectious disease, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement the surgical mesh, Strattice, utilized during hernia surgery. Findings:  Biologic mesh is derived from human or porcine dermis, after having been processed into acellular, porous extracellular matrix scaffolds of collagen and elastin. The theoretical advantages of biologic mesh over synthetic mesh include reduction of chronic inflammation and foreign body reaction, stiffness and fibrosis, and mesh infection. However, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) notes that there is a lack of data regarding the performance of biologic mesh in the setting of primary or recurrent ventral or inguinal herniorrhaphy in the non-contaminated and previously uninfected field. At this time, the medical evidence has not demonstrated the superior effectiveness of the services at issue. All told, the surgical mesh, Strattice, utilized during hernia surgery was not likely to have been of greater benefit than other available treatment options.Final Result: Two of the three reviewers determined that the services at issue were 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:  All three reviewers are board certified in surgery 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.