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

A 60-year-old female enrollee has requested for an MRI of the right knee for evaluation of her knee pain. Findings:  The physician reviewer found that the patient has advanced arthritis of her right knee with radiographs that demonstrate bi-compartmental degenerative changes. MRI would not provide any additional medical information that would change her treatment plan given this diagnosis. In addition, there has been no recent acute soft tissue injury documented in the record that would suggest the need for an MRI.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old male enrollee requested authorization and coverage of the medication Actiq. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees central neuropathic pain syndrome.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: An enrollee has requested authorization and coverage for surgery to extract a mass forming in the vagina for treatment of the enrollees prolapsed uterus. Findings:  The physician reviewer found that this patient presents with a prolapsed uterus. Pelvic relaxation and uterine prolapse is sometimes managed surgically, typically with a vaginal procedure, such as a vaginal hysterectomy and vaginal suspension, which requires the patient being in a high-lithotomy position with the legs flexed on the abdomen. Prolapse also can be managed non-surgically by placement of a pessary, which is an insert placed into the vagina that holds the uterus back into its natural position. The placement of a pessary is frequently successful, resolves the symptoms of prolapse, and avoids the risks of surgery. In cases where there are medical or orthopedic issues making surgery risky or challenging or impossible, this is an excellent option. In the medical literature, noted that first-line management of pelvic organ prolapse (POP) is conservative therapy. The author found that the mainstay of nonsurgical treatment for POP is the vaginal pessary. In this case, the providers documented that this patient cannot tolerate the high-lithotomy position necessary for vaginal surgery, so a pessary fitting is the next recommended step for this patient, and not surgery. For these reasons, the requested surgery to extract a mass forming in the vagina is not medically necessary for treatment of this patients uterine prolapse. Final Result: The reviewer determined that the requested surgery 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for outpatient therapy services, once per week. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The progress notes do not include a description of the exact symptoms that are being treated in therapy. The patient has several issues of stress in life, including marital stress and parents illness. However, it is unclear as to whether the enrollees symptoms are improving or worsening. There is no description of exact therapeutic techniques, such as cognitive behavioral therapy or other forms of evidence-based mental health treatment. There is no clear description of treatment goals for the patients therapy. The DSM-5 indicates that functional impairment must be present in order for a set of symptoms to classify as a mental illness. The progress notes do not detail any functional impairment, as they are simply lists of problems that the patient is experiencing. Based on the documentation provided for review, there is no clinical indication that this patients therapy needs to occur on a weekly basis. Therefore, outpatient therapy services, once per week, were not and are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry 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

The patient is a 50-year-old obese female who has requested authorization for Xenical. The patient is 54 weighing 172 pounds with a body mass index (BMI) of 29.5 and has been unsuccessful with dieting. The Health Plan has denied authorization for Xenical. The patient meets nationally accepted criteria for authorization of Xenical. Xenical is indicated for patients with a BMI of greater than 30 or for patients with a BMI of greater than 27 with comorbid conditions such as diabetes and hypertension. This patient has a BMI of greater than 27 with comorbid conditions. The average weight loss with Xenical is 12 to 15 pounds  usually within the first six months. Furthermore, there is substantiated evidence that Xenical combined with lifestyle change and weight management support is beneficial for the treatment of obesity. Based upon the information set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old female enrollee has requested pelvic floor physical therapy for treatment of her pelvic floor dysfunction.  Findings:  The physician reviewer found that at several of her PT sessions, the patients records described her as relatively asymptomatic. Although she was being treated for presumed pelvic floor dysfunction, the records indicate that that condition was not consistently causing her problems. In addition, the patient noted to her gynecologist that she was not finding the PT treatments helpful. Overall, the sessions at issue do not meet the published criteria for PT as they were not being provided to achieve a specific diagnosis-related goal and were not likely to increase the patients function. As such, the medical necessity of the therapy at issue has not been demonstrated in the records provided for review. Accordingly, I have determined that the therapy at issue was not and is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Praluent 75 mg /mL for treatment of the enrollee who has a history dyslipidemia. Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity for the requested medication. In this case, the records do not indicate that this patient has completed an adequate trial with Zetia in addition to maximally tolerated statins. The provider noted that Zetia would not be effective in lowering the patient to her LDL goals. However, the providers statement was not supported by the submitted clinical records or current peer-reviewed medical literature. Specifically, there was no documentation regarding a trial or failure of Zetia for this patient. As such, Praluent 75 mg/mL is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intravenous immunoglobulin (IVIG) (HCPCS - J1569 Gammagard). In the peer-reviewed medical literature, researchers reported that systematic review of available trial and case report data did not reflect clinical significant benefit from use of IVIG with treatment of adult related multiple sclerosis. Cross and Naismith similarly reported that IVIG had not shown significant benefit in a majority of patients treated both acutely and chronically with IVIG for multiple sclerosis in adults. The medical records indicate that this patient is an older adult with multiple sclerosis. IVIG has not demonstrated significant short- or long-term benefit for treatment of adult related multiple sclerosis. The records do not reflect any mitigating circumstances such as signs of immune related encephalitis. Thus, the requested IVIG (HCPCS - J1569 Gammagard) is not medically necessary for the patient based on the medical records provided for review. 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 neurology 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Linzess. The patient has diagnoses of diverticulosis in the entire colon, external and internal hemorrhoids, and a normal ileum, epigastric pain, and chronic idiopathic constipation. The American Gastroenterological Association Medical Position Statement on Constipation states that the first line of therapy should be an osmotic agent, followed by another type of laxative, such as a stimulant laxative. Linzess has been approved by the U.S. Food and Drug Administration (FDA) for chronic constipation. Clinical trials showed Linzess significantly increased weekly spontaneous bowel movements and complete spontaneous bowel movements while reducing abdominal pain. Linzess is not specifically a laxative. It has a different mechanism of action than osmotic laxatives and can be effective even if agents such as laxatives and fiber have failed. In this case, the patient has failed treatment with an osmotic laxative, a stimulant laxative, and a bulk-forming laxative. Medical evidence supports the requested medication in this clinical setting. Therefore, Linzess 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genetic screening (MyRisk) for evaluation of the enrollees risk of cancer.Findings:  The physician reviewer found that the genetic screening (MyRisk) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The MyRisk panel testing is considered a standard of care for patients in this clinical setting. The patients father appears to be unavailable for testing and had colon cancer and a brain tumor younger than age 50 increasing the patients risk of Lynch syndrome. The MyRisk panel detects disease-causing mutations in the MLH1, MSH2, EPCAM, MSH6, PMS2 and MYH genes that are responsible for the majority of Lynch syndrome and MYH-associated polyposis (MAP) cases. A positive test would allow risk reducing screening and decrease in the patients cancer risk. Based on the clinical documentation submitted for review, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee requested 20 hours per week of in-home applied behavioral analysis (ABA) services for treatment of the enrollees medical condition. Findings: Two physician reviewers found that according to the documentation submitted for review, the patient was diagnosed as autistic at the age of five, based on formal psychological testing. The diagnosis of autism by the psychologist is strong evidence that supports the patient as autistic. In addition, the school districts IEP describes the patient with many autistic features such as lack of eye contact and avoidance of social peer relationships. Given the confirmation of autism supported by the psychological testing and school district IEP, 20 hours of in-home ABA therapy is medically necessary in this clinical setting. Final Result: Two reviewers determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  One reviewer is board certified in pediatrics and child neurology and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing.  One reviewer is board certified in child neurology and is 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

A 22-year-old female enrollee has requested Nexium for the treatment of her gastrointestinal reflux disorder (GERD) and hiatal hernia. Findings:  The physician reviewer found that pharmacologic therapy for gastroesophageal reflux disease (GERD) continues to focus on optimizing acid suppression. Proton pump inhibitors (PPIs) continue to be the backbone of acid suppression therapy, providing excellent relief of symptoms and healing of erosive as well as nonerosive esophagitis. All PPIs are essentially equivalent in healing control of intragastric pH over 24 hours, and act by covalently binding to cysteine residue in H, K ATPase (the proton pumps) in the membrane of the secretor canaliculi of parietal cells. For the most part, all PPIs are equivalent in their efficacy to control acid secretion. However, inter-patient variability of the efficacy has been demonstrated with PPIs because of the degree of the dependence of PPIs on polymorphically distributed P450 (CYP) 2C19.  However, milligram for milligram all drugs in this class appear comparable in their effects with regard to clinical or endoscopic end points or side effect profiles.
Appeal type: Experimental/Investigational
Decision: Overturned

A 54-year-old female enrollee has requested authorization and coverage for a full body PET scan for evaluation of the enrollees cervical cancer.  Findings:  Three physician reviewers found that the patient has stage IV cervical cancer. The patients cancer was noted to have invaded the bladder and there was also noted involvement of the periaortic lymph nodes at the time of diagnosis. She was originally diagnosed in two years prior and subsequently treated with surgery, chemotherapy and radiation therapy. The patient also has a distant history of right breast cancer, which was treated with mastectomy and chemotherapy. The patients bone biopsy, performed was noted to be benign. Her most recent PET/CT scan showed no evidence of recurrence. A follow-up PET/CT scan for surveillance purposes was recommended by the patients provider. The Health Plan has denied this request, which is the subject of this review. The peer reviewed medical literature evidences ample support for the use of PET/CT studies for the surveillance of patients with known cervical cancer. The National Comprehensive Cancer Network (NCCN) guidelines indicate that in the case of patients at high risk for loco-regional failure, a combined PET/CT scan may be useful for detecting asymptomatic disease. Whole body FDG-PET scan is a sensitive imaging modality for the detection of recurrent cervical carcinoma in both symptomatic and asymptomatic women (Unger, et al.) and aids in deciding treatment plans and, eventually, may have a favorable impact on prognosis and patient survival (Chung, et al.).  Important in cases of asymptomatic patients is the fact that surveillance FDG-PET can detect asymptomatic recurrent disease that is potentially amenable to salvage therapy (Brooks, et al.)  This patient has a history of advanced cervical cancer and is at high risk for developing recurrence. A PET/CT study can detect recurrent cancer that may be asymptomatic. The outcome of the PET/CT scan may have a direct impact on the treatment plan for this patient.  In conclusion, the requested whole body PET/CT scan is likely to be more beneficial for evaluation 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 Intracept procedure. This patients records document a history of low back pain that has been treated with facet injections, non-steroidal anti-inflammatory drugs (NSAIDs), radiofrequency ablations, and epidural steroid injections without adequate pain relief. The patient has requested treatment with the Intracept procedure. The current peer-reviewed medical literature provides substantial data demonstrating the long-term efficacy and safety of the Intracept procedure in the treatment of patients with chronic low back pain as compared to ongoing conservative care. Fischgrund and colleagues noted that patients who underwent treatment with radiofrequency ablation of the basivertebral nerve for chronic low back pain exhibited significantly greater improvement in Oswestry Disability Index (ODI) at three months and a higher responder rate than sham treated controls. Truumees and colleagues found that minimally invasive radiofrequency ablation of the basivertebral nerve demonstrated a significant improvement in pain and function in patients with chronic vertebrogenic-related low back pain. Given this support, the requested Intracept procedure 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 services are 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 reviewer 1 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz XR for treatment of the enrollees rheumatoid arthritis. Findings:  The physician reviewer found that the American College of Rheumatology (ACR) guidelines for treatment of RA recommend methotrexate (MTX) with or without tumor necrosis factor inhibitor (TNFi) as the next treatment option in those who have failed MTX alone. In regards to the use of Xeljanz (tofacitinib) for treatment of RA, the guidelines state, there are potential longer-term safety concerns related to tofacitinib that need more study, partly related to the shorter experience using tofacitinib.  The guidelines recommend TNFi with or without MTX over tofacitinib as there may be some potential longer term safety concerns related to tofacitinib. More studies of tofacitinib were recommended. In this patients case, the patient has failed MTX, sulfasalazine and prednisone.  However, she has not failed a second TNFi or a non-TNF biologic agent as recommended by the guidelines.  During the patients most recent evaluation, no tender joints were reported on examination. Therefore, Xeljanz XR is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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.