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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Trulicity (0.75 mg/0.5 mL per injector). Findings:  The physician reviewer found that  glucagon-like peptide-1 receptor agonists (GLP-1 RAs), such as Trulicity, are one of the preferred approved treatment options for people with type 2 diabetes (T2D) and inadequate glycemic control. The author further notes that GLP-1 RAs help in regulating insulin secretion in proportion to environmental glucose levels, have a low risk of hypoglycemia, facilitate weight loss, and may also have beneficial effects on the cardiorenal system, including reducing cardiovascular risk and improving renal outcomes. Nauck and colleagues report that given the effectiveness for hemoglobin A1c (HbA1c) reduction with additional weight reduction and without intrinsic risk of hypoglycemic episodes, GLP-1RAs are recommended as the preferred first injectable glucose-lowering therapy for type 2 diabetes, even before insulin treatment. In this case, the records note that the patients glycemic control is not currently at goal and that her endocrinologist recommended Trulicity. In this clinical setting, the requested medication is medically indicated. Therefore, Trulicity (0.75 mg/0.5 mL per injector) is medically necessary for the 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 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: Experimental/Investigational
Decision: Upheld

The parent of a 14-year-old male enrollee has requested rituximab infusion for the treatment of the enrollees rheumatoid factor polyarthritis. Findings:  Three physician reviewers found that rituximab is well-established and FDA approved treatment for rheumatoid arthritis in adults and has extensive support in the literature for its efficacy in this disease, as noted by Furst and colleagues. There have been no controlled trials of rituximab in juvenile rheumatoid arthritis, and it is not approved by the FDA for use in the pediatric population. Its use in a pediatric patient would be considered off-label. In the study by El-Hallak and colleagues, rituximab was used in ten pediatric patients with autoimmune diseases. In this series, one patient died and three had serious infections.  The medical literature does not support the use of rituximab in juvenile rheumatoid arthritis. While rituximab might be considered as a therapy if the patient fails other standard therapies, other available disease-modifying anti-rheumatic drugs have not been tried.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old male enrollee has requested a lumbar spine MRI for evaluation of his back pain.  Findings:  The physician reviewer found that for patients with uncomplicated back pain (this includes patients with no history of cancer, no clinical suspicion of infection, no history of recent trauma and no neurological deficits),  it is medically appropriate to undergo a trial of conservative therapy including NSAIDs and physical therapy prior to advanced imaging such as MRI.  This has been well-established in the medical literature. If the patients symptoms persist or worsen with conservative therapy, then an MRI may be appropriate. As there is no documentation of a recent trial of conservative therapy and this patient has uncomplicated back pain, the requested diagnostic procedure is not medically indicated in this patients case.  All told, the requested lumbar spine MRI is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 19-year-old female enrollee has requested a home sleep study for evaluation of her history of headache and fatigue.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue.  If this patients treating provider suspected obstructive sleep apnea, appropriate screening tests, such as an Epworth Sleepiness Scale or Stanford Sleepiness Scale, should have been performed prior to ordering this test.  Additionally, the medical records do not demonstrate that questions regarding the presence of habitual snoring, observed apneas, excessive daytime sleepiness or nocturia were asked.  Such efforts may have altered the probability that she suffered from obstructive sleep apnea.  The current medical evidence does not support the services at issue in this patients case. In this clinical scenario, the home sleep study was not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C virus. Findings:  The physician reviewer found that per the guidelines, all patients with chronic active hepatitis C virus (HCV) are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. 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. The evidence supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. The goal of treatment of HCV-infected persons is to reduce mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure. While the patient is an appropriate candidate for antiviral therapy, the proposed treatment regimen of Harvoni for 12 weeks is not medically necessary to successfully treat his condition. A study by medical researchers showed no difference in sustained viral response between 8 and 12 weeks of treatment in patients without cirrhosis and whose HCV viral load was less than 6 million IU/mL. As such, 8 weeks of Harvoni as opposed to 12 weeks is medically appropriate in this clinical setting. Thus, the proposed regimen of 12 weeks of Harvoni is not medically necessary for treatment of the patients hepatitis C virus. 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

A 52-year-old female enrollee has requested for Tarceva for treatment of her metastatic ependymoma. Findings:  Two physician reviewers found that National Comprehensive Cancer Network guidelines for the treatment for recurrent ependymoma recommend etoposide, temozolomide, nitrosurea and platinum based regimens or participation in a clinical trial. Other sources make similar treatment recommendations. The clinical literature included for review provides information regarding clinical trials of Tarceva for glioblastoma multiforme. Recurrent ependymoma is a different type of brain tumor. There are no published peer reviewed studies demonstrating the efficacy of Tarceva for the treatment of recurrent ependymoma. While Tarceva may have some minimal activity in high grade gliomas, clinical investigation is still in the early stages.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old male enrollee has requested radiofrequency turbinate reduction for treatment of his nasal congestion/obstruction.  Findings:  Two physician reviewers found that there is abundant literature on the use of radiofrequency ablation of soft tissue for treatment in the setting of OSA. At this time, the majority of the of the research involves  inferior turbinate reduction for chronic nasal congestion/obstruction that has failed to respond to medical management. This patient is the perfect candidate for radiofrequency reduction and it is medically appropriate in this instance. His underlying medical problems increase the risk of general anesthesia, he has failed medical therapy and he is willing to use the nasal CPAP to treat his OSA.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a 6-year-old female enrollee requested authorization and coverage of speech therapy for the treatment of a severe speech disorder.  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 therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with right knee osteoarthritis. The provider noted that the patient has been treated with bilateral arthroscopic knee surgery, naproxen, and Flexeril. The provider noted that weight bearing x-rays of the right knee revealed end-stage arthritis of the lateral compartment. The patient reported right knee lateral joint line pain. The provider noted the patient was being treated with physical therapy. A right knee steroid injection was administered. The patient reported that the right knee steroid injection provided pain relief until one week prior. Physical examination findings included right knee valgus alignment. The patient has requested authorization and coverage for a Synvisc-One injection in the right knee. The Health Plan denied the request and reported that the requested service is not medically necessary for the treatment of this patient. At issue in this case is whether a Synvisc-One injection in the right knee is medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patients options are limited. He has tried and failed other conservative treatments, including a corticosteroid injection and physical therapy, with the alternative being a total knee arthroplasty. The medical evidence supports the requested service in this clinical setting. Therefore, a Synvisc-One injection in the right knee is medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested service 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 orthopedic surgery 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 mother of a 14-year-old female enrollee has requested  for a lumbar spine MRI for evaluation of the enrollees back pain.    Findings:  The physician reviewer found that an MRI of the lumbar spine is a useful imaging tool to evaluate for spinal disease, including disc herniation and spinal stenosis.  An MRI of the lumbar spine is medically appropriate for evaluation of back pain in certain instances, including patients with neurological deficits and those patients who have worsening symptoms following conservative therapy (i.e., physical therapy and NSAIDs). This patient has no neurological abnormalities on physical exam, and there is no documentation of a trial of physical therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Harvoni for treatment of the enrollees hepatitis C virus. 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 nonliver-related conditions. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per the guidelines, treatment naive, genotype 1 patients should be treated with Harvoni. Patients with viral loads less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. AASLD/IDSA guidelines cite data showing reduced survival with delayed 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 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 56-year-old female enrollee requested authorization and coverage of Accutane. The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollees skin condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for a Posey Bed (fully enclosed canopy style or enclosed sleep system). Sherberne and colleagues report that there is scant information in literature that discusses the use of an enclosure bed in a pediatric setting. The authors noted that in a review of 208 pediatric enclosure bed encounters in an acute care setting over a two-year period, there were several cases of falls, skin breakdown, and injury while using an enclosure bed. The authors noted sitter usage as an option for severely agitated children. In this case, the patient has multiple medical, developmental, and behavioral issues, including epilepsy, intellectual disability, agitated behavior, and severe mixed obstructive/central sleep apnea treated with continuous positive airway pressure (CPAP) therapy. In this clinical setting, a fully enclosed bed presents risks of injury or strangulation from the oxygen tubing and monitor wiring. Given these safety concerns, the requested equipment is not medically indicated. Therefore, a Posey Bed (fully enclosed canopy style or enclosed sleep system) is not medically necessary to prevent disease, disability, and other health conditions or their progression.Final Result: The reviewer determined that the requested equipment 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 neurology with special qualification in child 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computerized axial tomography (CAT) scan of the heart. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of serum cholesterol borderline.Findings:  Based on the records provided the patient is asymptomatic with increased coronary risk due to hyperlipidemia and a strong positive family history. In this circumstance, current guidelines for the evaluation and management of hyperlipidemia are available. These guidelines do not recommend routine screening with coronary CAT scanning.  Specifically for this patient, his 10 year risk for developing coronary disease is less than 7.5%. This patient has a risk score of 6.3% such that a statin medication would be recommended, regardless of the results from a coronary calcium scanning. For these reasons, CAT scan of the heart was not likely to have been more effective than the available standard methods of evaluating this patients medical condition. Final Result: All three 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested authorization and coverage for dry needling acupuncture for a history of perineal pain. A urology consult determined it was perineal pain of unclear etiology; possibly perineal muscle spasm or strain. The diagnosis was adductor strain and treatment included an exercise program and additional therapy sessions. Findings:  The physician reviewer found that dry needling acupuncture is the practice of acupuncture, and is used within the management of trigger point versus selection of a specific acupuncture point in management of neuropathic pain. Dry needling acupuncture is not medically necessary for management of pudendal neuralgia (PN), given the condition is neuropathic pain versus management of a specific trigger point.  Acupuncture, as a procedure, is the stimulation of anatomical locations on the body, alone and in combination, to treat disease, injury, pain, and dysfunction and to promote health and wellness. Acupuncture, includes the invasive stimulation of said locations by the insertion of needles and the non-invasive stimulation of said locations by thermal, electrical, chemical, light, mechanical or other manual therapeutic methods. Trigger point dry needling, dry needling, functional dry needling, and intramuscular manual therapy, or any other pseudonym describing acupuncture procedures, are, by definition, the practice of acupuncture. The specific effect of acupuncture on chronic prostatitis/chronic pelvic pain syndrome remains unclear. Further research is warranted to examine the mechanisms by which acupuncture therapy may improve clinical symptoms in patients with chronic prostatitis/chronic pain syndrome. The patient's diagnosis of pudendal neuralgia would not necessitate use of dry needling given that no specific trigger point involvement was identified by physical examination. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The reviewer is board certified in acupuncture and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Lyrica for treatment of her medical condition. Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the superior effectiveness of the requested medication.  This patient was diagnosed with chronic right knee pain.  Lyrica is an anticonvulsant which is approved for chronic pain associated with neuropathic pain, fibromyalgia and diabetic neuropathy.  There is lack of support in the medical literature for treatment of chronic knee pain with this medication.  Thus, Lyrica is not likely to be more efficacious than other treatment alternatives in this clinical setting.  Final Result: The reviewer determined that the requested medication is 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: The reviewer is board certified in anesthesiology with sub-specialty 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

The father of a 16-year-old male enrollee requested authorization and coverage of surgical correction of the enrollees gynecomastia. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees gynecomastia.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.