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

Nature of Statutory Criteria/Case Summary: An enrollee has requested admission into an acute brain rehabilitation facility for treatment of the enrollees traumatic brain injury.  Findings: The reviewer found that the Functional impairments due to traumatically acquired brain insults may improve with time via natural recovery processes.  These impairments are also amenable to rehabilitation interventions.  Nevertheless, deficits can remain severe, particularly in the setting of severe injuries.  Functional dependency following intracerebral hemorrhage is high.  In this case, the patient has sustained extensive bi-frontal and bitemporal hemorrhages.  Follow-up imaging has shown chronic encephalomalacic changes, and even early volume loss.  Although there has been some improvement, he has had persistent behavioral issues.  Otherwise, from the physical standpoint, there are no documented significant deficits that indicate a need for ongoing inpatient level care for his rehabilitative needs.  His treating providers have not recommended acute inpatient rehabilitation.  Further rehabilitative services may be considered going forward, but these services can be provided in a community setting, with custodial level services provided for his basic self-care.  There are otherwise no documented ongoing skilled nursing needs (e.g., complex wound care, initiation of self-care related to enteral feeding or ostomy care) requiring ongoing inpatient care.  This patient has a guarded long-term prognosis given the severity of his underlying brain injury condition.  An acute inpatient rehabilitation course at this time would not be reasonably expected to positively modify his health or functional outcomes in a marginally significant manner over less intensive services.  All told, admission into an acute brain rehabilitation facility 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

A 21-year-old female enrollee has requested residential treatment center (RTC) services for treatment of her anorexia nervosa and depression.  Findings:  The physician reviewer found that review of the medical records shows that at the time of admittance to the RTC, the patients weight was increasing and she was cooperating with therapy with good participation in group therapy. In addition, her vital signs and lab tests continued to be normal, and her mood and anxiety were reported to be at the low to moderate level.  Suicidal ideation was not evident and no self injurious behaviors were noted. Moreover, her family was reported to be supportive. Given these findings, the patient no longer required the intensity of service of a residential treatment level of care as of the date in question.In sum, residential treatment services during the time at issue were not medically necessary for treatment of the patients medical and mental health conditions. This finding is made in consideration of the patients history, clinical course during treatment, physical condition and overall clinical and psychological status. Partial Hospitalization (Full-Day Out-Patient Care) would have been the appropriate level of care and was medically necessary for treatment of the patients condition as of the original date.
Appeal type: Experimental/Investigational
Decision: Overturned

A 56-year-old male enrollee requested a wearable cardioverter defibrillator for medical treatment of his medical condition.  Findings:  Two physician reviewers found that a wearable cardioverter defibrillator offers a potential prophylactic strategy for patients considered at high-risk for sudden cardiac death due to ventricular tachycardia or ventricular fibrillation, but who are not defined to be immediate candidates for permanent automatic cardioverter defibrillator devices.  Currently accepted considerations for use of this device include as a bridge to automatic cardioverter defibrillator devices implantation or until the arrhythmic risk is felt to have subsided.  This patient presented with new onset of non-ischemic cardiomyopathy and marked impairment of left ventricular systolic function.  In this clinical setting, utilization of a wearable cardioverter defibrillator was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right sacroiliac (SI) joint fusion surgery (CPT 27280). The International Society for Advancement of Spine Surgery (ISASS) support SI joint fusion surgery for well-selected patients who have failed conservative treatment. Documentation should support the presence of significant SI joint pain confirmed by at least three positive SI joint provocative tests, confirmation of the SI joint as a pain generator with at least 75% decrease in pain following fluoroscopically guided diagnostic intra-articular SI joint block, and failure to respond to at least six months of non-surgical treatment. Moreover, additional or alternative diagnoses that could be responsible for the patients ongoing pain or disability should be ruled-out. Evidence based medical literature supports the use of open SI joint fusion as safe and effective for patients with SI dysfunction refractory to non-operative management. This patient presents with a history of constant moderate to severe right SI joint pain with functional limitations in activities of daily living. Clinical examination findings have documented right SI joint pain and five positive SI joint provocative tests. There is radiographic evidence of minimal degenerative changes. She has failed to improve with long-term conservative treatment including physical therapy, chiropractic care, medications, and lumbar support. She underwent a diagnostic SI joint injection with 90% reduction in pain, and a previous SI joint injection with benefit. In this case, there is evidence of SI joint pain that has failed to respond to long-term comprehensive conservative treatment. The patient has positive signs and clinical examination findings demonstrating that the SI joint is the source of her pain. Moreover, these findings were confirmed with a diagnostic SI joint injection. All told, the requested right SI joint fusion surgery (CPT 27280) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested right SI joint fusion surgery (CPT 27280) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The 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 reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Tymlos. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients osteoporosis. The submitted documentation does not support the medical necessity of the requested medication. Fractures are the most dangerous aspect of osteoporosis. Until recently, pharmacological options for the treatment of osteoporosis have been limited to antiresorptive agents, including the oral bisphosphonates. Newer treatment agents have become available over the past few years, including Tymlos (abaloparatide), a synthetic analog of parathyroid hormone-related peptide. Anabolic agents, such as this have been shown to improve bone mass and decrease fracture risk in osteoporosis patients by directly stimulating osteoblasts to produce new bone. Other relatively new agents are also currently available for treatment of osteoporosis, such as Prolia and Forteo.  Forteo is a recombinant form of the biologically active component of parathyroid hormone which has been shown to increase bone mass and prevent fractures in osteoporotic bone. Recent data also demonstrates that Forteo may aid in the healing of fractures and non-unions in osteoporotic patients.  As such, this may be an ideal agent for this patient. The Health Plans requirement that the patient try a formulary agent prior to Tymlos is medically appropriate. Therefore, the requested Tymlos is not medically necessary for 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 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: The patient has requested authorization and coverage for physical therapy. Findings:  The physician reviewer found that Persistence of symptoms beyond the generally accepted time frame of two weeks for recovery of concussion is referred to as post-concussion syndrome. The mainstay of treatment for concussion and post-concussion syndrome include rest, gradual return to activities, and self-management strategies. Some rehabilitation interventions in the early setting have been shown to be effective in addressing functional concerns for this condition, but there is a lack of data to draw conclusions about the effectiveness of individualized rehabilitation for post-concussion syndrome patients. The records provided for review document chronic, persistent symptoms following remote head traumas. The patient has some subjective clinical benefit from rehabilitation efforts. Treatment has included adequate rehabilitation and education to be independent with a home exercise and self-management program. Although the patient reports ongoing symptoms, there is a lack of expectation that additional formal physical therapy will result in a marginally significant benefit over an independent program. All told, the requested physical 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 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

A 64-year-old male enrollee has requested for CyberKnife radiosurgery for treatment of his prostate cancer. Findings:  The physician reviewer found that there is a lack of peer-reviewed scientific data demonstrating a significant difference in complication events following traditional external beam radiation compared to CyberKnife therapy in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld

enrollee has requested reimbursement and prospective authorization and coverage for onabotulinumtoxinA (Botox) injections in the pelvic floor muscle. The current medical literature does not support the utility of Botox as within the standard of care for treatment of myofascial pelvic floor pain. Although there are a few studies suggesting its efficacy, the available medical literature consists of small retrospective case series with a limited number of patients. In the absence of adequate data demonstrating improved health outcomes on long-term follow-up, the Botox injections in the pelvic floor muscle provided were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Baraclude for treatment of the enrollees hepatitis B. Findings:  The physician reviewer found that This patient is currently on brand-name Baraclude (entecavir). Per American Association for the Study of Liver Disease guidelines for treatment of hepatitis B, Baraclude (entecavir) is a recommended medication. Entecavir-mediated viral suppression is a first-line therapy recommended by the guidelines, and has been shown to decrease the risk of decompensation and hepatocellular carcinoma. However, the brand formulation is not recommended over the generic formulation. Additionally, generic medications must demonstrate bioequivalence, with the exact same active ingredient, to be approved for use.  The manufacturer of generic entecavir for sale in the United States did demonstrate equivalence to brand-name Baraclude to the U.S. Food and Drug Administration before approval was granted. There is a lack of medical literature to show that brand-name Baraclude is safer or more effective than generic entecavir.  For these reasons, Baraclude is not medically necessary for the 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested enrollee has requested reimbursement for DecisionDx-Melanoma test. Findings:  The physician reviewer found that there is lack of evidence in the medical literature as to the superior efficacy of the services at issue over standard techniques in the evaluation of this patients medical condition. As such, the services at issue are not considered standard of care in this clinical setting and its usage is not expected to affect the management of the patients melanoma. The results from the testing would not change treatment recommendations. Accordingly, the DecisionDx-Melanoma test was not likely to have been of greater benefit in the management of this patient than the available standard techniques. Final Result: All three reviewers determined that services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three reviewers are board certified in dermatology 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

The patient is an 18-year-old female with a several year history of varying degrees of bulimia nervosa consistent with the criteria outlined in the Diagnostic & Statistical Manual of Mental Disorders IV. The patient was admitted to residential treatment center level of care on 4/19/04 and her stay was authorized by the Health Plan until 5/25/04. In addition to her eating disorder, the patient also has major depressive disorder and is being treated with psychotherapy and Prozac 60mg per day. Although not described as actively suicidal, the patient continues to indulge in self-harm with scratching, picking and stabbing sharp objects into her skin. The patient has an apparent history of failed inpatient and intensive outpatient treatment. In addition, there are possible post-traumatic stress disorder symptoms related to apparent sexual abuse that has only recently been discussed in individual and family therapy. The patient has made progress in the residential treatment center program and seems independently motivated to remain in treatment. Her recent past history is subnormal body weight, bradycardia, and electrolyte imbalance as a result of her eating disorder. According to the clinical records provided the patient is reported to have reached her ideal body weight with normal electrolytes and heart rate.A request has been made for continued residential treatment services. The Health Plan states that the submitted documentation does not demonstrate that residential treatment services were medically necessary after 5/25/04.Based on the submitted medical records, it appears the patient has greatly benefited from her five-week authorized stay at residential treatment center level of care. However, the information provided demonstrates that by 5/25/04 the patients condition had stabilized and improved enough for the patient to be transitioned to partial hospitalization level of care for continuation of her treatment. The Health Plans recommendation that the patient be transferred to a less intensive level of treatment is consistent with national and local community standards of care. As of 5/25/04, the patient was reported to have reached her ideal body weight with normal electrolytes and heart rate, and was stable from a psychiatric standpoint. As such, there is no medical indication for continued residential treatment services.Based upon the information set forth above, I have determined that the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested Harvoni for medical treatment of his hepatitis C virus.  Findings:  Three physician reviewers found that per the American Association for the Study of Liver Diseases (AASLD) and Infectious Disease Society of America (IDSA) recommendations for testing, managing, and treating hepatitis C, Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Therefore, regardless of fibrosis, the patient should be approved for treatment of HCV. Thus, Harvoni is medically necessary for 12 weeks for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee requested authorization and coverage of gastric bypass surgery with duodenal switch for the treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested type of bypass is not medically necessary.  The plan recommended a Roux-en-Y gastric bypass.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested type of gastric bypass is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested gene testing for evaluation of his drug metabolizer status.  Findings:  Three physician reviewers found that in the documentation available for review, no rationale was given for the testing at issue. The peer-reviewed medical literature suggests that it is premature to recommend routine therapy adjustment for oxycodone on the basis of CYP2D6 genotype. Additional studies state that the need to test for NSAID tolerance before prescribing has not been established in the medical literature. All told, the requested gene testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:   All three physician reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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.