Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement for allergy testing services. This patient presents with a history of food allergies. The patient underwent allergy testing in January of 2021 as part of his treatment regimen. While oral food desensitization has reportedly been achieved in the majority of patients in randomized controlled studies, few patients successfully develop tolerance or sustained unresponsiveness. The standard of care in this clinical setting includes measurement of IgE levels to specific foods for an individual patient. However, an extensive array of blood tests and oral desensitization to a multitude of foods in the absence of a history of anaphylaxis is not supported by the peer-reviewed medical literature or clinical guidelines. Moreover, an extensive array of blood tests that examine aeroallergen component IgE as well as food IgG4 testing has not been shown to add clinical benefit in the evaluation of patients with food allergies. All told, the allergy testing services were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the allergy testing services were not 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 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: Physician reviewer 1 is board certified in allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in allergy and immunology and is actively practicing. Physician reviewer 3 is board certified in pediatrics with subspecialty certification in allergy and immunology 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: Overturned

The enrollee is requesting reimbursement for residential treatment center (RTC) services. He has a history of alcohol and benzodiazepine abuse. He started using Xanax and Klonopin daily. He has a history of seizures, a brain injury, post-traumatic stress disorder, post-concussion syndrome and hypertension. He entered a chemical dependency unit for detox, was placed on phenobarbital, completed detox and was discharged to a residential program. He left the residential program after a week but reverted to former alcohol consumption habits until he re-entered the chemical dependency unit. He successfully detoxed with Ativan and was discharged to residential treatment care (RTC) services. The admission assessment indicates post-acute withdrawal symptoms of anxiety, headache, anger, obsessive-compulsive thinking, depression, mood swings, cravings and panic. His admission diagnoses were alcohol dependency, uncomplicated; sedative, hypnotic or anxiolytic dependency, uncomplicated; major depressive disorder, single episode; and panic disorder. The progress note indicates agitation, cravings and a depressed feeling.  He had been experiencing some anxiety, was sweating and appeared paranoid. He successfully completed 30 days of residential treatment and was discharged for transition to sober living and an intensive outpatient psychiatric (IOP) program.  The physician reviewer found that  six dimensions of Level of Care Utilization System (LOCUS) include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. For risk of harm, the enrollees score is 3, due to continued alcohol abuse and benzodiazepine use. For functional status, the enrollees score is 3, due to the enrollees still working with chronic functional impairments. For comorbidity, the enrollees score is 3, due to alcohol abuse, benzodiazepine abuse and history of trauma. For recovery environment level of stress, the enrollees score is 3, due to maternal relationship acting as a trigger for addictive behavior. For recovery environment level of support, the enrollees score is 3, due to the enrollee having a sober friend who provides assistance. For treatment and recovery history, the enrollees score is 4, due to a history of relapse. For engagement and recovery status, the enrollees score is 3, due to the enrollee having limited engagement. The enrollees composite LOCUS score is 23, which correlates with residential treatment level of care.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee has requested acupuncture services for the treatment of her headaches. Findings:  The physician reviewer found that the patient has had a less than favorable response to traditional medicine.  Acupuncture is a viable treatment alternative for her medical condition.  It is used to treat not only postsurgical pain and nausea associated with pregnancy or chemotherapy, but also more usual problems such as muscle pain, headaches, addiction and asthma.  Acupuncture should be considered in this case, as traditional medicine has seemingly been of little or no help, and there is no other specified alternate treatment.  Furthermore, records submitted indicate it has already provided the patient with significant relief.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Botox injections at the dosage of 200 units every three months for treatment of the enrollees migraine headaches. Findings:  The physician reviewer found that medical studies support the use of greater than 155 units every three months and the general practice by the majority of headache specialists is to administer greater than 155 units. Specifically, medical guidelines allow for some customization by providers. Some studies have looked at doses higher than 155 units and these studies have found that higher doses than 155 units were more effective in treating migraine headaches. One study used 260 units and found Botox was effective; but, this same study found that at higher dosing, more side effects were noted. On the other hand, other Botox-migraine studies where 195-260 units were used; the participants had no serious adverse events. In this patients case, the dosage of 200 units every 3 months is clinically supported. Also relevant, is this patients history of receiving 200 units every 3 months for an extensive period of time with no documented adverse effects to the dosing.  In sum, the dosage of 200 units every three months are medically necessary for the treatment of this patients migraine headache.  Final Result: The reviewer determined that the requested medication and dosage 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 neurology 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 54-year-old female who has requested a Cox-2 inhibitor after a trial of non-steroidal (NSAID) medications. The patient has tried a number of NSAID medications without success. The Health Plan has recommended other NSAID medications for the patient prior to consideration of a Cox-2 inhibitor. The Health Plans policy is reasonable and appropriate and consistent with evidence-based standards.There is no advantage over Cox-2 inhibitors over traditional NSAIDs. There is some potential advantage for individuals with gastrointestinal intolerance of NSAIDs but this advantage is questionable and has not been established in the evidence-based literature. The Health Plan is offering the patient appropriate medications for treatment of the patients condition. There is no evidence that a Cox-2 inhibitor is medically necessary at this time. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:    An enrollee has requested a consultation with a perinatologist, an ultrasound conducted by the perinatologist, and fetal echocardiography for treatment of her early pregnancy hemorrhage.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. In this case, the patient does not have any medical or pregnancy conditions that require a referral for a consultation with a perinatologist. Although she experienced vaginal bleeding, this resolved without treatment. In addition, two ultrasounds showed normal maternal, fetal and placental anatomy. According to the American Institute of Ultrasound in Medicine (AIUM), an ultrasound assessment of fetal anatomy is indicated but does not need to be conducted by a perinatologist.  Similarly, a fetal echocardiography is not medically necessary as there is no related family history and no medical problems or medication exposures that would increase the risk of cardiac malformations in this fetus. Based on the clinical documentation submitted, a consultation with a perinatologist, an ultrasound conducted by the perinatologist and fetal echocardiography are not medically necessary for treatment of the patients medical condition.  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 obstetrics and gynecology with sub-specialty certification in maternal and fetal 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested implantation of the ExPRESS mini glaucoma shunt for treatment of the enrollees glaucoma.  Findings: Three physician reviewers found that there is a lack of independent medical data establishing the superior efficacy of the Ex-press mini glaucoma shunt implantation for treatment of glaucoma. While this procedure appears promising, in order for the patient to be considered for this procedure, the standard form of treatment for glaucoma should be exhausted.  In the records provided, there is no indication that this has taken place. Therefore, the implantation of the ExPRESS mini glaucoma was not likely to be of greater benefit than other available standard therapies for treatment of the patients glaucoma.Final Result: Three reviewers determined that the procedure at issue was 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 physician reviewers 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested monitored anesthesia during a colonoscopy for treatment of her medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient did not present with a significant history that would require monitored anesthesia care.  The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and comorbid conditions that would put the patient at risk during the procedure.  There is no documentation of comorbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care.  All told, monitored anesthesia during a colonoscopy was not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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 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 Percocet 10/325 mg. The U.S. Food and Drug Administration (FDA) discussed the nature of generic medications and their regulation. The FDA concluded that generic drugs are created to be the same as an already marketed brand-name drug in dosage form, safety, strength, route of administration, quality, performance characteristics, and intended use. These similarities help to demonstrate bioequivalence, which means that a generic medicine works in the same way and provides the same clinical benefit as its brand-name version. In this case, the provider prescribed Percocet for the patients pain control until she undergoes back surgery. Although the prescription is for Percocet, a generic version of the medication, which is oxycodone-acetaminophen, is on the Health Plans formulary. A review of the patients Controlled Substance Utilization Review and Evaluation System (CURES) report demonstrates that the patient filled prescriptions for oxycodone-acetaminophen in August and September 2019 and there was no report of adverse events in the medical records available for review. Based on the available medical records for review, and the FDAs section on generic medications, the requested brand name Percocet is not indicated. Accordingly, the requested Percocet 10/325 mg is not medically necessary for 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 anesthesiology with subspecialty 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: Medical Necessity
Decision: Overturned

A 30-year-old female enrollee requested authorization and coverage of gastric bypass surgery for the treatment of obesity.  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 surgery is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old male enrollee requested a single Mohs procedure to remove all of his facial basal cell carcinoma lesions for treatment of his medical condition.Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The treatment of choice for basal cell carcinomas of the face, particularly a recurrent basal cell carcinoma, is Mohs micrographic surgery.  However, the submitted records fail to demonstrate the medical indication for treating all lesions in a single day.  If a lesion is particularly large or the closure is expected to be complicated or encroach on the border of another lesion, performing the procedure at separate visits may be indicated.  It is at the determination of the surgeon as to the best way to proceed with removal of the lesions and how many lesions can be safely treated at one time.  The recommendation that each lesion be treated at a separate visit is medically appropriate.  All told, the requested for a single Mohs procedure to remove all of the patients facial basal cell carcinoma lesions is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her medical condition.  Findings:  The physician reviewer found that 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. This applies regardless of fibrosis stage or viral load. Per the AASLD/IDSA guidelines, Harvoni is first-line therapy for treatment-naive genotype 1 patients. These guideline 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. The guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection.  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 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

A 36-year-old female enrollee has requested for Botox injections  for treatment of her chronic migraine headache with vertigo component.  Findings:  The physician reviewer found that this patient has a chronic daily headache disorder, but it is most consistent with chronic tension type headache or daily persistent headache. The records from her providers do not confirm that an FDA approved treatment paradigm has been followed to achieve this outcome. All told, the patients symptoms do not meet the criteria for chronic migraine. Therefore, the Botox treatment Botox therapy have not been demonstrated to be medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for pioglitazone HCL 30 mg tablets.The American Diabetes Association (ADA) recommends a target HbA1c of less than 7% in order to decrease the risk of micro and macrovascular complications. The ADA also recommends diet management and weight lost for better glycemic control. In this case, the patient's type 2 diabetes was in poor control with a reported HbA1c level of 11-13% on a regimen of glipizide and metformin. The patient was also noted to have had difficulty in achieving weight loss. The patient was started on pioglitazone after the combination of glipizide and metformin was ineffective. This is a triple therapy regimen that is recommended by the ADA, and the patient is following ADA guidelines by using glipizide, metformin and pioglitazone. Accordingly, pioglitazone HCL 30 mg tablets are medically necessary to treat the patients condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal 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: Overturned

A 37-year-old male enrollee has requested Euflexxa injections for the treatment of his knee pain. Findings:  The physician reviewer found that viscosupplementation has a documented moderate positive effect on patients with osteoarthritis of the knee. The osteochondral defect of the medial femoral condyle is clearly degenerative, as evidenced by the patients age, the associated degenerative meniscal tear, and the chondromalacia of the patella.  These are all components of the osteoarthritis spectrum and osteoarthritis is noted as a diagnosis. Thus, there is evidence that the patient does indeed have osteoarthritis of his knee and therefore the requested Euflexxa injections are medically necessary and should be covered.
Appeal type: Urgent Care
Decision: Overturned

A 37-year-old female enrollee has requested emergency services for the treatment of her condition. Findings:  The physician reviewer found that the patient was suffering from a severe headache associated with nausea, vomiting, visual changes, slurred speech and other symptoms for which a prudent layperson would reasonably seek immediate medical attention due to fear for jeopardy to her health and bodily function.  The differential diagnosis of the patients presenting symptoms includes migraine headache (and variants), cerebral-vascular accident, intra-cerebral bleeding and other potentially serious disorders.