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

The representative of an 18-year-old male enrollee requested authorization and coverage of a discogram and consideration of intradiscal electrothermal therapy (IDET) for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees back pain.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old male enrollee has requested for medications including Pegasys (peginterferon alfa-2a) and Ribavirin for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that the records provided for this patient fail to demonstrate the necessity of the requested medications. There is no liver panel provided for review or discussion of prior therapies and the patients response to previous treatment. In the absence of detailed information documenting this patients liver panel results and his previous treatment regimen, the medical necessity of the proposed medications is not established.
Appeal type: Medical Necessity
Decision: Upheld

A 24-year-old male enrollee has requested 24 intensive outpatient treatments for treatment of his opioid dependence and major depressive disorder, recurrent, moderate, without psychosis. Findings:  The physician reviewer found that this patient has a diagnosis of opiate dependence and polysubstance abuse as well as major depression disorder, recurrent, moderate, without psychosis. Based upon the submitted documentation, this patient appeared to be improved, and his substance abuse was under control.  He was not showing the symptoms of his mood disorder, as his mood was much improved, with minimal anxiety.  He was not resistant to a structured program, and his environment was not unsupportive.  The patient was willing to cooperate and was motivated.  He was able to maintain abstinence with minimal support. All told, the requested 24 intensive outpatient treatments are not medically necessary for this patient. Although the patient is not a candidate for the requested 24 intensive outpatient treatments at this time, he is an appropriate candidate for a lower level of care.  Outpatient treatment level of care is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested a Synvisc One injection and Synvisc One injections, one every six months for the 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.  The evidence-based literature supports the use of repeat series of viscosupplementation injections as safe and effective for the treatment of pain in patients with osteoarthritis of the knee when significant improvement in symptoms has been achieved for six months or more and symptoms recur.  There is a lack of reliable evidence that any one brand of hyaluronic acid is superior to other brands for medically necessary indications.  In this patients case, there is a lack of evidence indicating that she was intolerant to, or had failed other hyaluronic acid injections.  While repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee are supported by the medical literature, future authorization should be based on response to prior injections.  A blanket future approval would not be medically appropriate. Therefore, the requested Synvisc One injection was not medically indicated.  Also, Synvisc One injections, one every six months 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 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: Experimental/Investigational
Decision: Upheld

The parent of a 10-year-old male enrollee has requested  for biofeedback therapy for treatment of the enrollees constipation. Findings:  Two physician reviewers found that paraoxical external anal sphincter contraction during attempted defecation (anismus) is thought to be an important contributor to chronic fecal retention and encopresis in children. Biofeedback training can be used to teach children to abolish this abnormal contraction. Multiple randomized trials have been performed in medical treatment resistant and treatment dependent encopretic children and none of these trials have shown any benefit of biofeedback therapy over enhanced toilet training in children with encopresis.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested Harvoni for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that based on the information provided, which includes two non-invasive assessments of liver fibrosis, the patient has minimal to no fibrosis.  This is despite having been infected with hepatitis C for many years.  He is unlikely to gain meaningful benefit from eradication of hepatitis C, and his prognosis is excellent.  This patient should have significant fibrosis in order to warrant treatment with Harvoni.  In this clinical setting, longitudinal assessments via noninvasive measures of fibrosis are medically appropriate.  All told, Harvoni is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for Otezla (apremilast) medication. The enrollee is diagnosed with moderate to severe plaque psoriasis. According to his provider, other medications have been avoided due to their immunosuppressive properties and side effects, and that disease-modifying antirheumatic drugs (DMARDs) and ultraviolet light have been avoided due to anxiety, depression, and the sensitive area of plaque. There are no head-to-head studies comparing the multiple medications available at this time to treat psoriasis.  In an enrollee such as this, they list apremilast as a first line agent along with multiple other agents. Otezla has been effective in treating this enrollees condition. There is a risk in changing medications at this time. Very recent data indicates that patients started on apremilast were as likely as patients started on a biologic agent to still be on the same medication after a year. These data suggest that the effectiveness of apremilast can be expected to continue. Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in dermatology 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested monitored anesthesia care provided during a colonoscopy for evaluation of her abdominal pain, diaphoresis, and loose stools.   The physician reviewer found that this patients records do not document any of the serious risk factors or medical conditions that would warrant monitored anesthesia care. There is no evidence of serious airway issue, cardiopulmonary disease, craniofacial issue, or evidence of high dose opioid use that would necessitate anesthesia as opposed to conscious sedation. All told, monitored anesthesia care provided during a colonoscopy was not medically necessary for evaluation of this patients medical condition. 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

A 39-year-old female enrollee requested authorization and coverage of gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.Three physician reviewers performed a medical necessity Independent Medical Review. Two physician reviewers concluded that the requested procedure is not medically necessary for treatment of the enrollee's medical condition. One physician reviewer concluded that the requested procedure is medically necessary for treatment of the enrollee's medical condition. Because two of the three  physician reviewers concluded that the requested procedure is not medically necessary for treatment of the enrollee's medical condition, the Health Plans denial was upheld.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting authorization and coverage for the medication VersaBase. The enrollee is a post-menopausal female on hormone replacement therapy (HRT). During an office visit with her obstetrician-gynecologist, she stated she wanted to continue compounded therapy because she tolerated it well. She considered switching to an FDA-regulated bioidentical HRT, but when she tried patches, Estradiol and Premarin, she experienced cramping, nausea and diarrhea. She has been taking VersaBase for over five years for hormone dysfunction. All other medications available for this condition failed due to allergic reactions and gastrointestinal problems. After a through examination and detailed history, her physician determined she should stay on the same medication as it has worked well for her.The physician reviewer found the use of compounded preparations of hormones, known as bioidentical hormones, for the treatment of menopausal symptoms can be an attractive alternative for those suffering from unrelieved menopausal symptoms. These compounds should be approached with caution. Professional societies warn the ability to accurately assess and measure potency, efficacy, and quality of the preparations is lacking. Furthermore, these compounds are not FDA-approved.Additional concerns surfaced regarding the nature of these compounds and their impacts on overall health and well-being when a correlation was discovered by Australian researchers between endometrial cancer and the use of these unregulated compounds. A professional societys position statement has remained unchanged on this issue since 2006; the compounds are not recommended. Further, these compounds have not been studied comprehensively, and there is no definitive evidence regarding the safety of these compounds. Claims to the contrary have no scientific foundation for their validity.The physician reviewer found that determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in obstetrics and gynecology and reproductive endocrinology 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a referral with a bariatric surgeon and bariatric revision surgery for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Weight regain following gastric bypass surgery is often behavioral, and the success rates of revisional surgery are variable.  The durability of weight loss is not known.  There is a lack of support for the requested services in this clinical setting.  The records do not demonstrate a concerted attempt at nonsurgical weight loss prior to the requested revisional surgery.  Additionally, records reflecting long-term follow-up with her bariatric program and an aftercare program were not provided.  An evaluation for surgically correctable causes of weight regain should include an upper gastrointestinal series.  Based upon the medical records, the requested referral with a bariatric surgeon and bariatric revision surgery are not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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: Overturned

The patient is a 52-year-old male with a history of hepatitis C who is being treated with Peg-intron and ribavirin. There are issues with thrombocytopenia. The patients provider has recommended the use of Neumega to treat the low platelets so interferon can be continued. The Health Plan has denied authorization and coverage for Neumega on the basis that it is not medically necessary for treatment of the patients condition.The use of Neumega in this clinical setting is medically appropriate and indicated. It appears the patients provider is anticipating cutting back on the interferon dose in addition to using the growth factor. This is recommended in the setting of low platelets. The use of Neumega is medically necessary in order to continue the full course of therapy and to allow the patient to finish the treatment. Therefore, 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Tradjenta for treatment of the enrollees type 2 diabetes. Findings:  The physician reviewer found that Diabetes is a progressive disease, which typically manifests with increasing loss of glycemic control over time despite lifestyle and pharmacologic intervention.  Although type 2 diabetes is initially due to insulin resistance, studies have shown that patients with this disease also may have a decline in pancreatic beta cell function, which begins as early as 12 years before diagnosis and continues throughout the disease process.  Many clinicians now recognize the importance of avoiding prolonged hyperglycemia in patients with short diabetes duration in order to minimize its impact on decline of beta cell function and its potential effect on late microvascular and macrovascular complications.  A number of new diabetic medications have been developed recently which are frequently being used earlier in the course of treatment of diabetes.  Among these is the DPP4 inhibitors (DPP4i), such as Tradjenta, which are a class of newly developed antidiabetic drugs which help lower blood glucose levels and may help preserve pancreatic beta cell function.  While all of the members of the DPP4i class of medications appear to be efficacious for the treatment of diabetes, a potential advantage of Tradjenta over the other drugs of its class is that it is not extensively renally excreted, and it is instead eliminated primarily via the hepatic route. The Health Plan has offered coverage for renal dose-adjusted alogliptin as an alternative. However, even low dose alogliptin is excreted by the kidneys. Tradjenta appears to be preferable over the other members of its class for the treatment of diabetes in the presence of renal impairment. All told, Tradjenta 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 sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested reimbursement for magnetic resonance imaging (MRI) of the neck and total disc arthroplasty. This patient underwent evaluation with a cervical spine MRI less than one month prior to the repeat MRI. However, there is a lack of indication for the repeat MRI. The postoperative diagnosis was cervical spondylosis without myelopathy. Currently there are insufficient data demonstrating the long-term safety and efficacy of total disc replacement for the treatment of cervical spondylosis. Specifically, studies have not shown that disc replacement reliably and reproducibly fulfills the three primary aims of continued motion, clinical efficacy, and few adjacent segment degenerative problems. Total disc replacement has been associated with a high rate of future operations, and the potential problems that may occur with longer follow-up have yet to be determined. All told, the MRI of the neck and total disc arthroplasty were medically not necessary for 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 neurological 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: Overturned

The parent of a 12-year-old female enrollee has requested psychiatric residential treatment for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that the patient continued to manifest behavior that required medical intervention and containment in a 24-hour setting during the period at issue. The level of care provided is consistent with Child and Adolescent Level of Care Utilization System (CALOCUS) and American Academy of Child and Adolescent Psychiatry practice guidelines.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested for a sleep study and an oral device for evaluation/treatment of her obstructive sleep apnea.   Findings:  Two physician reviewers found that there was no documentation submitted regarding any outpatient evaluations. They are not indicated in patients with multiple medical comorbidities (see Collop and colleagues). No records of any clinical evaluations are included by the patients providers in the records submitted.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc-One, to be injected in the left knee, every six months. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals 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 individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, while there is no history of prior viscosupplementation. The patient reported that a corticosteroid injection was effective for only a couple months and a recent crepitus in the joint indicated worsening symptoms. Based upon the moderate degree of this patients osteoarthritis, a total knee arthroplasty would not be indicated. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Synvisc-One, to be injected in the left knee, every six months, is medically necessary for the treatment of this patient.Final Result: The reviewer 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: 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for laparoscopic sleeve gastrectomy. The records provided for review document that this patient has a BMI that is 35 kg/m2 without documentation of an associated serious obesity-related comorbid condition to support an indication for the requested bariatric surgical procedure (Mechanick, et al.). The patient has obtained surgical clearances from her dietary and behavioral health providers. However, there is no report of a serious obesity-related condition such as type 2 diabetes mellitus, hypertension, or obstructive sleep apnea to support severe obesity and laparoscopic sleeve gastrectomy. On sleep study, the patient was found to have disordered breathing without evidence of sleep apnea. All told, the requested laparoscopic sleeve gastrectomy is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in surgery with expertise in minimally invasive and bariatric 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.