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

A 43-year-old female enrollee requested monitored anesthesia care provided during a colonoscopy for medical treatment of her diagnosed Crohns disease.  Findings:  The physician reviewer found that monitored anesthesia care was not medically necessary for the treatment of this patient.  In this case, there is no documentation of comorbid conditions that would place this patient at risk for complications requiring the need for monitored anesthesia care.  Colonoscopy may be safely and effectively performed with conscious sedation in an office-based setting and without the need of monitored anesthesia care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Entresto. Findings: The records provided for review document that this patient presents with a history of sudden cardiac death and sustained ventricular tachycardia. The patient has been treated with an implantable cardioverter defibrillator (ICD) as well as medical therapy with losartan and metoprolol. The patients provider has recommended a change in medications from losartan to Entresto. In the medical literature, a study noted that the PARADIGM-HF study demonstrated benefits of treatment with Entresto to be consistent across a broad range of heart failure subgroups, including patients with clinically stable heart failure, as in this patients case. The authors found that Entresto improved patients quality of life and longevity as well as reduced hospital admissions. The authors concluded that Entresto has been shown to reduce the risk of cardiovascular death or heart failure hospitalization and improve symptoms among patients with chronic heart failure with reduced ejection fraction compared to enalapril, the gold standard angiotensin-converting enzyme inhibitor. The findings of the PARADIGM-HF study support the efficacy of treatment with Entresto for this patient given her history of sudden cardiac death and sustained ventricular tachycardia. For these reasons, the requested Entresto is medically necessary for 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 subspecialty certification in cardiology 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 her medical condition.  Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this patients case.  Breast tomosynthesis allows radiologists to separate dense glandular elements from underlying mass/architectural distortion, particularly in cases of extremely dense or heterogeneously dense tissue.  This advantage has been associated with a decrease in callbacks and increase in detection of small cancers.  Thus, the addition of breast tomosynthesis was likely of more benefit to this patient than had the exam been done with two-dimensional imaging alone.  Final Result: Three 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: All three 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha Sureclick 140 mg/mL for treatment of the enrollees hyperlipidemia and coronary artery disease. Findings:  The physician reviewer found that the request for Repatha Sureclick 140 mg/mL has been established as medically necessary for treatment of the patients medical condition. Based on the records provided the patient has not been able to tolerate moderate or high dose statin or Zetia. Repatha is U.S. Food and Drug Administration (FDA) approved for individuals with genetic hyperlipidemias or for established atherosclerotic vascular disease and failure to achieve treatment goals for lipid lowering at maximally tolerated doses of statins. In this case, the patient meets these criteria. 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 cardiovascular 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: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested the medication Crestor (rosuvastatin) for the treatment of her dyslipidemia.  Findings:  The physician reviewer found that although both Zocor and Lipitor are non-hydrophilic and Pravachol and Crestor are hydrophilic, the incidence of adverse effects including fatigue and myalgias is similar in each of the four drugs. There is little evidence that switching from a non-hydrophilic to a hydrophilic agent is likely to reduce the risk of adverse effects if one has already had such a response. At high doses, Crestor will lower triglycerides by 23 to 28%, increase HDL by 8 to 16% and lower LDL by 34%. At similarly high doses, Pravachol will lower triglycerides by 24%, increase HDL by 12% and lower LDL by 34%. Although the patient may experience adverse side effects with Lipitor, a clinical trial of this drug is reasonable before prescribing Crestor.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 24-year-old female with a BMI of 46. She has comorbid conditions including hypertension. She wishes to undergo gastric bypass. She has undergone a formal psychological evaluation and has been found to be an appropriate candidate for weight loss surgery.With a BMI of 46 and comorbid conditions, the patient meets accepted national medical necessity criteria for consideration of weight loss surgery. In addition, the patient has undergone a psychological evaluation and is considered an appropriate candidate for weight loss surgery. Roux-en-Y gastric bypass is medically indicated and medically necessary for treatment of this patients morbid obesity. Furthermore, scientific evidence does not show that structured weight management plans consisting of diet and exercise have been successful in the treatment of the morbidly obese. The study referenced above demonstrates that surgery has the best long-term outcome for the morbidly obese.Based upon the information set forth above, I have determined that the requested procedure 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: The patient presented for a physical therapy evaluation on 7/29/18.  The records indicated difficulty with ambulation due to pain and fatigue. The patient ambulates short distances inside the home using a four-wheeled walker with a seat. She lives with relatives in a wheelchair-accessible single level home, and does not spend time alone in the home. The records noted that she has a group 2 power wheelchair in good mechanical condition, which she uses intermittently in the home and to access an outdoor mailbox. She has adequate support to assist with shopping and transportation to medical appointments. On examination, the patient was noted to be obese with active range of motion in the upper and lower extremities within functional limits. She is independent for transfers and toileting.  The patient requires assistance for bathing and dressing tasks. Her standing balance is impaired and she ambulates with an antalgic gait between 10 and 20 feet with use of a walker. Physical examination on 8/29/18 demonstrated normal findings in the respiratory and cardiovascular systems, and no extremity edema. There were no documented neurological deficits. The patient has requested authorization and coverage for an electric wheelchair or a power scooter. The Health Plan has denied this request and reported that the requested equipment is not medically necessary for the treatment of this patient. The submitted documentation fails to demonstrate the medical necessity of the requested equipment. The provider observed that the patient ambulates with a walker, but the records do not document significant cardiovascular, respiratory, musculoskeletal, or neurological impairment. A physical therapy mobility evaluation indicated that the patient has functional range of motion and strength in the limbs and she is able to transfer independently. She has an antalgic gait but is otherwise able to ambulate short distances with a walker. She has a functioning group 2 power wheelchair. The patient desires a portable scooter or electric wheelchair that can be disassembled (by someone other than herself) for transport. The records do not indicate that the patient has impairments that would preclude her from using a walker or properly fitted manual wheelchair to accomplish mobility-related activities of daily living. Therefore, the requested electric wheelchair or a power scooter are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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

An enrollee has requested authorization and coverage for Norco 5-325 mg. U.S. Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioids for non-cancer pain state that nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. CDC guidelines state that clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation.  American Society of Interventional Pain Physicians (ASIPP) guidelines for prescribing opioids state that to establish medical necessity for opioid therapy, it is essential to have a physical diagnosis and information on inadequacy of multiple modalities of treatments including conservative, various other alternatives, and consultations if necessary. In this case the patient has chronic low back pain without radiation into the lower extremities. There are no findings of focal neurological deficits on exam in the submitted documentation, and the patients lumbar MRI and X-rays have not revealed any significant narrowing of the spinal canal or nerve root foramen. The patient has tried and failed medication management with anti-inflammatories, anti-depressants and lidocaine patches. The patient has made clear that he is not interested in trying any other non-opioid agents at this point. Other treatments including home stretching and yoga have also been tried with limited benefit. The treating providers did not feel the patient was a good surgical candidate due to a lack of an obvious therapeutic target. The CDC guidelines state that initiating or continuing opioid therapy is contingent on whether the prescriber feels the benefits outweigh the risks, which is not present in this case. The provider has suggested that the patient continue with non-opioid based therapy, consistent with CDC guidelines. In addition, ASIPP guidelines state that a physical diagnosis be established, while in this case, the patient has non-specific back pain, MRI does not show significant pathology that would correlate with the patients reported pain, and physical exam has not shown any obvious neurological deficit. Under these circumstances, there is nothing identified in the medical records that would warrant escalation to chronic opioid therapy. Accordingly, the requested Norco 5-325 mg is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty certification in pain 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a cold therapy machine that uses ice or ice water. Findings:  The physician reviewer found that various treatment options for patient with chronic abdominal wall pain and found that treatment protocol included abdominal wall injections or a localized removal of terminal branches of intercostal nerves. The authors did not include a cold therapy machine as part of treatment protocol. Another review of conservative to more invasive treatment options for abdominal wall pain by Shian and Larson found that local injections with an anesthetic and a corticosteroid were effective treatments for anterior cutaneous nerve entrapment syndrome, with an overall response rate of 70% to 99%, while for refractory cases that required more than two injections, surgical neurectomy generally resolved the pain. The review did not mention a cold therapy machine as a studied or proven therapy for this condition. Given the current medical literature, a cold therapy machine is not medically indicated for treatment of chronic abdominal wall pain. Therefore, a cold therapy machine that uses ice or ice water is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested device 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 anesthesiology with sub-specialty certification in pain management 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

A 31-year-old male has requested coverage for past transcranial magnetic stimulation therapy for treatment of his major depressive disorder.   Findings:  Two physician reviewers found that the submitted documentation indicates that the patients symptoms included anhedonia, cognitive impairment, interpersonal withdrawal, fatigue, suicidal ideation, and diminished work performance.  The provider noted that the patients prior medications included Prozac, Abilify, Lamictal, Pamelor, and Parnate.  He underwent electroconvulsive therapy in the past, with minimal improvement.  Per the American Psychiatric Association guidelines, transcranial magnetic stimulation is an appropriate acute phase treatment option for patients who do not respond adequately to medication therapy.  This patient has been treated with antidepressants of at least two different classes, as well as a mood stabilizer.  Per the medical records, electroconvulsive therapy was provided in the past, and the records noted only minimal improvement.  The current medical evidence supports the therapy at issue in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned

A 44-year-old female enrollee has requested a PET scan with CT for attenuation for evaluation of her history of malignant spindle cell sarcoma.  Findings:  Three physician reviewers found that this patient has suspected local recurrence of her spindle cell carcinoma as documented on MRI.  A PET scan with CT for attenuation has been requested to determine if the abnormal finding on the MRI is secondary to local recurrence and to determine if there is associated metastatic disease.  The requested diagnostic procedure would also be useful to determine the appropriate site for a biopsy, if clinically indicated.  There is sufficient support in the peer-reviewed literature for the use of PET scan with CT for attenuation in the restaging of patients with known soft tissue sarcoma.  Multiple studies have shown PET scan to be more accurate in restaging than conventional imaging, including CT and MRI.  All told, the requested PET scan with CT for attenuation is likely to be superior over all other methods of evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 47-year-old female enrollee has requested percutaneous tibial nerve stimulation (PTNS) for treatment of her urinary urgency and frequency.  Findings:  Two physician reviewers found that the peer-reviewed medical literature supports the use of PTNS in the treatment of urinary frequency, urgency, and incontinence with short-term efficacy in those who have failed medical management. The durability of treatment success achieved appears to be maintained by continued PTNS on a scheduled basis for an indefinite period, but the nature of this third-line approach has yet to define a statistically supported protocol. In addition, the therapeutic choice for PTNS based upon this patients limited medication trials and signs of improvement with only initial pelvic floor training falls outside the standard of care. Overall, there is a lack of current evidence to suggest that PTNS would be more therapeutic than other available second-line therapies for treatment of this patients urinary symptoms.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested an eight-week course of Harvoni 90/400 mg for medical treatment of his hepatitis C virus. Findings:  Two physician reviewers found that the current guidelines emphasize that those patients most likely to benefit from viral eradication should be treated with a direct-acting antiviral (DAA) hepatitis C drugs. Individuals with advanced fibrosis and/or severe disease activity would benefit the most such as those with extrahepatic manifestations such as cryoglobulinemia, which this patient is not known to have. In this clinical setting, the patient should be followed by fibrosis parameters serially and begin therapy if there is evidence of histologic progression. For the reasons provided, the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for rituximab (Rituxan).  The Health Plan has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees membranous nephropathy.Findings:  There is support in the medical literature for the requested medication in this clinical setting. Rituximab is an accepted therapy for membranous glomerulonephritis and is considered a standard of care. The documentation provided supports the use of rituximab in this patient. Moreover, peer-reviewed literature has indicated the efficacy of rituximab for treatment of membranous glomerulonephritis. This patient has failed Ponticelli protocol and has documented persistent proteinuria. Therefore, rituximab (Rituxan) is more likely to be a greater benefit over the standard therapy for the treatment of this patients medical condition. Final Result: All three reviewers have determined that the requested medication is likely to be more beneficial for treatment of your medical condition than any available standard therapy.Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty certification in nephrology 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 41-year-old female enrollee has requested for an orthopedic specialist consultation for treatment of her carpal tunnel syndrome. Findings:  The physician reviewer found that patient has tried splinting and injections, and she still has ongoing discomfort from carpal tunnel syndrome. Further non-operative care is not likely to be of benefit. A referral to an orthopedic specialist will provide a more detailed evaluation and allow for patient education regarding the conservative and operative treatments of this condition.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee has requested for an electric scooter for treatment of her post-polio syndrome. Findings:  The physician reviewer found that the patient does have a mobility impairment. During her in- home PT evaluation, she demonstrated the ability to compensate for this by walking 50 feet twice with a single point cane and independence with her activities of daily living.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Viekira Pak plus ribavirin for treatment of his hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions.  Per the guidelines, treatment-naive genotype 1a patients should be treated with Viekira Pak and ribavirin for 12 weeks.  The guidelines also cite data showing decreased survival with delay in therapy.  For these reasons, the requested treatment with Viekira Pak and ribavirin is medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medications 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 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.