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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Duavee 0.45 mg/20 mg tablets. Findings:  The physician reviewer found that the request for Duavee 0.45 mg/20 mg tablets is medically necessary for treatment of the patients medical condition. Estrogen only regimens such as estradiol tablets and Estring are not medically appropriate in this clinical setting. In addition, Premarin vaginal cream is indicated only for local vaginal symptoms related to menopause. Systemic hormonal medications are the standard of care for treatment of vasomotor symptoms. In this case, the patient still has her uterus and endometrial protection provided by a combination estrogen/progesterone regimen is appropriate. Moreover, this patient has been treated with Duavee for several years and has been and doing well. The continued use of Duavee is medically necessary for treatment of the patients difficult to treat medical condition. For the reasons provided, the requested medication is medically necessary for treatment of the patients medical condition.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 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

A 43-year-old female enrollee has requested outpatient psychotherapy one session per week for treatment of her behavioral health condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. Current mental health practice is focused on aggressive treatment of anxiety and suicidality in the acute phase of illness, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery. Weekly sessions can be clinically appropriate in certain circumstances, particularly since psychotherapy is the cornerstone of treatment for anxiety disorders. However, in this case, the providers submitted summary of care letters lack a comprehensive psychiatric assessment and longitudinal documentation, including developmental history, treatment history, specific type of evidence-based therapeutic applications, patient-centered goals with quantifiable objectives to achieve said goals, barriers to progress, multidisciplinary contributions, physical examination and supportive community interventions which are needed to determine if weekly treatment is having a positive effect in bolstering autonomy and resiliency while mobilizing the patient towards remission. Although the patient remains symptomatic and in need of continued care, there is no evidence of grave disability or imminent threat due to the anxiety burden. In the absence of the aforementioned clinical documentation, the Health Plans authorization of outpatient psychotherapy sessions at a frequency of every two weeks is safe, reasonable and consistent with good medical practice. Thus, the services at issue were not and are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee, with a history of abdominal pain, cramps, nausea, vomiting and constipation, has requested authorization and coverage for colonic irrigation. Findings:  The physician reviewer found that there is no specific literature or evidence in peer-reviewed journals on the efficacy of colonic irrigation in the management of patients with IBS. Thus, at present, the benefits of colonic enema/irrigation remain unproven.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a 12-year-old male enrollee requested authorization and coverage for the medication Adderall XR.  The health plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees Attention Deficit Disorder (ADD).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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of the enrollees hepatitis C virus.  Findings: The physician reviewer found that while this patients records may not support advanced fibrosis, current American Association for the Study of Liver Diseases/Infectious Diseases Society of America (AASLD/IDSA) recommendations support the medical necessity and medical appropriateness of HCV treatment. Per the guidelines, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This guideline applies regardless of fibrosis stage or viral load. In this case, treatment with Harvoni is medically indicated. Therefore, the requested Harvoni for eight weeks is medically necessary for treatment of the patients medical condition.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 physician 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 35-year-old male enrollee has requested vertebral axial decompression for the treatment of his sciatica and three herniated discs. Findings:  Three physician reviewers found that there is insufficient evidence available in the peer-reviewed journals to support the use of vertebral axial decompression for treatment of the patients condition.  As the clinical literature is lacking, the procedure remains of unproven efficacy. Although there may be anecdotal reports of decompressive therapy providing relief, this is not supported by the scientific studies available. It is also not clear as to whether the patient has tried all other standard treatments.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female has requested posterior spinal fusion L5-S1 for treatment of her low back pain. Findings:  The physician reviewer found that in the treatment of low back pain, most patients resolve without surgery, with physical therapy and non-steroidal medications as the cornerstone of non-surgical treatment.  In mechanical back pain, surgery should only be considered after conservative measures have been exhausted, as noted by Bambakidis and colleagues. Lumbar fusion is rarely indicated for routine discectomy or abnormal results of radiography without appropriate clinical findings.  In this case, there is a lack of documentation of conservative care. The patient was reported to have refused epidural injections, but there is no report of the use of other medications, such as NSAID medications, and no report of the results of other treatment modalities, such as physical therapy.  In addition, the physical examination notes pain on motion, but there is no documentation of any observed loss of motion, spasm, or any loss of sensory, motor, or reflex functions. There is no documentation of any other studies, such as electrodiagnostic testing.  All told, posterior spinal fusion L5-S1 is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for V-Go 20. Ginsberg notes that the V-Go pump is one of a group of newly developed patch pumps that promise accurate and flexible insulin delivery. Thompson and Cook note that patch pump delivery systems offer several advantages over conventional insulin pump delivery systems, including being small, lightweight, and free of tubing. Grunberger and colleagues report that initiating V-Go therapy may significantly improve glycemic control and lead to significant insulin dose reductions for patients with type 2 diabetes previously managed with multiple daily injections of insulin. In this clinical setting, the requested device is medically indicated. Therefore, V-Go 20 is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Repatha for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that there is a lack of support for the requested medication in this patients case.  There is no documentation to support a definitive history of homozygous familial hypercholesterolemia or heterozygous hypercholesterolemia.  These conditions usually manifest by a combination of physical examination findings and low-density cholesterol levels that are at minimum above 180 mg/dl.  Repatha is a PCSK9 inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of low-density cholesterol.  This patients records do not support either of those criteria.  PCSK9 inhibitors have not been studied in other patient populations such as this patient.   Also, current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting.  All told, Repatha is not medically indicated for the 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an automated insulin delivery device for treatment of the enrollees type 1 diabetes. Findings:  Two physician reviewers found that Continuous glucose monitoring systems including real-time systems have U.S. Food and Drug Administration (FDA) approval. However, they are not the subject of Phase I-III clinical trials. The American Diabetes Association position statement on standards of medical care in diabetes states that CGM may be a supplemental tool to [self-monitoring of blood glucose] SMBG in those with hypoglycemia unawareness and/or frequent hypoglycemic episodes. The Medtronic is a partially automated, closed-loop hybrid system to deliver insulin. It is a hybrid system (not fully automated), in that only the basal insulin doses are automatically adjusted depending on CGM results. Patients need to manually request prandial insulin doses. Although the preliminary results for partially automated, closed-loop system are promising, additional large scale long term trials are need. A study evaluated the safety of a hybrid closed-loop system in patients with type 1 diabetes. The authors concluded that, Longer-term registry data and randomized studies are needed to further characterize the safety and efficacy of the hybrid closed-loop system. At this time, the incremental benefit of automated closed-loop control of insulin administration is unclear. There is a lack of long term data available demonstrating health outcome benefits of such technology compared to other treatment methods, including multiple daily injection therapy and continuous insulin infusion therapy with or without a threshold suspend device with or without CGMS. The requested device, Medtronic lacks long term studies showing it is benefit for the treatment of patients with type 1 diabetes. Final Result: The reviewers determined that the requested device 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

The patient is a 24-year-old male with an approximate one-year history of diabetes who is requesting authorization for an insulin pump. He is presently on a multiple daily insulin injection (MDII) regimen of glargine and supplemental short-acting insulin. On 9/30/04, the patients A1c was 5.9%. Multiple self-monitored blood glucose values submitted from 3/14/04 to 6/11/04 showed excellent control. A 9/30/04 progress note for the patients provider noted great control. As of 10/1/04, the patients endocrinologist has not suggested any changes to the patients current regimen.Analysis and Findings:The patients blood sugars are well controlled with his present MDII regimen. For many people the MDII regimen provides control equivalent to insulin pump therapy. Although pump therapy may provide greater life-style flexibility for the patient, no documentation has been submitted demonstrating a medical need for insulin pump therapy. Therefore, I have determined the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for HP Acthar gel 80 Unit/mL (2 x 5 mL vials), injected twice per week. Psoriasis is a chronic inflammatory skin disease that typically presents with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation. Psoriasis has a high negative impact on the quality of life, especially in patients with moderate or severe disease. Long-term use of traditional systemic therapies is frequently unacceptable due to side effects and limited efficacy. Although there are numerous agents available, for patients with refractory disease that continue to experience tender and/or swollen joints, pain, and disease activity, HP Acthar gel may be indicated. Repository corticotropin injection (HP Acthar gel) produces steroid-independent, anti-inflammatory and immunomodulatory effects in patients with rheumatic disorders, such as psoriatic arthritis. Current studies have demonstrated that repository corticotropin injection is a safe and effective option for patients with refractory psoriatic arthritis who failed therapy with multiple previous treatments. The records provided for review document that this patient has failed treatment with topical steroids, Otezla, and prednisone. Given these findings, the requested HP Acthar gel 80 Unit/mL (2 x 5 mL vials), injected twice per week 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 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 a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 43-year-old female has requested continued posterior tibial nerve stimulation for treatment of her interstitial cystitis.  Findings:  Three physician reviewers found that the patient has had progressively painful periods and was diagnosed with significant endometriosis. She was also noted to have pelvic pain, pain with intercourse, urinary urgency and frequency and midline lower abdominal pressure. She was treated for her endometriosis with LAVH/BSO, cystoscopy and hydrodistention. She was noted to have multiple areas of petechiae involving all four quadrants of the bladder at the time of cystoscopy and was treated post operatively with bladder instillations for her interstitial cystitis. She also has been taking Prelief and antihistamines, however, she continued to have pelvic pain and began treatments with posterior tibial nerve stimulation (PTNS). The provider noted that these treatments have been decreasing the patients pelvic pressure, pain, urinary urgency and frequency symptoms. The peer-reviewed medical literature has not shown substantial data confirming that PTNS results in sustained improvement of urinary urgency or frequency or pain associated with interstitial cystitis. In fact, several studies have demonstrated that any improvements resulting from PTNS tend to be short-term in nature and there is often a need for chronic maintenance treatments to maintain any results (Kim, et al.). Other available studies have reported on short-term efficacy and lack blinding, sham/placebo groups or both to mitigate potential bias. Therefore, PTNS remains investigational, as the need exists for further randomized, controlled trials examining the long-term efficacy of PTNS (Cooperberg and Stoller).
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing. Findings: Three physician reviewers found that inherited thrombophilia is a genetic tendency to venous thrombosis. The most common inherited thrombophilias are the factor V Leiden mutation and the prothrombin gene mutation. Homozygosity for methylenetetrahydrofolate reductase (MTHFR) polymorphisms is a relatively common cause of mildly elevated plasma homocysteine levels, but these mutations do not appear to increase the risk of venous thromboembolism in pregnant or non-pregnant women. High-quality epidemiologic studies have not found a significant increase in venous thromboembolism risk among individuals homozygous for MTHFR polymorphisms. Routinely screening for inherited thrombophilias in unselected populations is not recommended because of the low frequency of the condition becoming symptomatic and the lack of a safe, long-term method of prophylaxis against thromboembolism. Furthermore, there is a lack of strong evidence on which to base recommendations regarding whom to test or the optimal panel of tests. There is a lack of evidence of a causal association between inherited thrombophilia in women with a history of recurrent or non-recurrent early fetal loss, and a lack of evidence that administration of anticoagulant drugs to such women is effective in improving pregnancy outcomes. Therefore, genetic testing was not likely to have been of greater benefit than other methods of evaluating this patient. 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 clinical genetics and genomics and is actively practicing. Physician reviewer 2 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewer 3 is board certified in obstetrics and gynecology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for substance abuse residential treatment center detoxification services. The submitted documentation supports the medical necessity of the services at issue. Upon presentation, the patient was in active withdrawal. His blood pressure was elevated.  He was disheveled in appearance, irritable in his disposition and restless in his behavior. His mood was anxious. He was nauseated, sweating and not sleeping well. Further, he had history of psychiatric comorbidity. He did not have a safe and sober housing or a supportive social network. He was abusing multiple substances and was at high-risk for a complicated withdrawal syndrome.  Based on this clinical data, admission for supervised detoxification was safe, appropriate and consistent with good medical practice. The services and setting were reasonably expected to improve the patients condition, prevent a more serious episode of illness and establish a patient-centric comprehensive outpatient treatment plan. Additionally, the duration of detoxification services aligned with community standards. Therefore, substance abuse residential treatment center detoxification services were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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.