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

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for the medication Myrbetriq 25mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees urinary incontinence; urinary urgency; voiding dysfunction; pelvic floor dysfunction; and overactive bladder.At issue in this case is whether the requested Myrbetriq 25mg is medically necessary for treatment of the enrollees medical condition.Fluid management behavioral therapy is the primary treatment for patients with symptoms related to overactive bladder. However, patients often require additional therapy with pharmaceuticals. The American Urological Association guidelines regarding treatment of overactive bladder suggest treatment of symptoms of overactive bladder with antimuscarinics and/or Beta 3 agonist. These medications are often used in conjunction with primary treatment options. Researchers concluded that mirabegron (Myrbetriq) 50mg had similar efficacy to most antimuscarinics and lower incidence of dry mouth, the most common adverse event reported with antimuscarinics and one of the main causes of discontinuation of treatment. Beta 3 agonist Myrbetriq is approved for treatment of symptoms related to overactive bladder. Treatment of this patients symptoms with Myrbetriq is indicated. Therefore, Myrbetriq 25mg daily is medically necessary.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 urology 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 27-year-old female enrollee has requested an upper GI endoscopy with biopsy for evaluation of her gastroesophageal reflux disease.  Findings:  The physician reviewer found that recommendations for upper GI endoscopy are age-specific and symptom-specific. In a patient at an age of low risk of esophageal or gastric malignancy, such as this patient, medical management of acid reflux symptoms first, prior to upper GI endoscopy, is appropriate. In this patients case, there is a low risk of Barretts esophagus because of her young age, her sex, and the new onset of symptoms.   Per the American Society for Gastrointestinal Endoscopy guidelines for upper GI endoscopy, the requested services are not medically indicated for this patient.  Per these guidelines, for patients with uncomplicated gastroesophageal reflux disease, an initial trial of empiric medical therapy is appropriate. These guidelines note that endoscopy is recommended for patients who have symptoms suggesting complicated gastroesophageal reflux disease or alarm symptoms such as obstruction with swallowing, upper GI bleeding, or significant weight loss.  These symptoms are not present in this patients case.  All told, the requested upper GI endoscopy with biopsy is not medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast cancer screening.  Findings: Two physician reviewers found that as a basic observation, DBT is rapidly becoming a standard tool in evaluating dense breasts or suspicious calcifications. A study evaluated the impact of adding DBT to full field digital mammography (FFDM) in the detection and diagnosis of breast lesions. The study demonstrated that screening sensitivity of full field digital mammography was increased from 60% to 94%, and specificity increased from 20.7% to 74% when DBT was applied. In addition, DBT allowed unnecessary biopsy to be avoided in 37.3% of patients. In this case, there are multiple indications for tomosynthesis for this patient. Her breasts are described as heterogeneously dense and tomosynthesis has the ability to separate out the overlapping structures enabling the possibility of demonstrating an otherwise occult tumor. Furthermore, tomosynthesis will better define a mass, especially when it is palpable. Based on the support in the peer-reviewed literature, the DBT was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure 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: All three physician reviewers are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Upheld

A 45-year-old female enrollee has requested for a Bionicare Unit for treatment of her arthritis.   Findings:  Three physician reviewers found that there is not sufficient evidence to support the use of the Bionicare device for the treatment of knee osteoarthritis. More long-term and class I data is needed to support the use of the Bionicare device for the treatment of degenerative joint disease of the knee.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a consultation with a vascular surgeon. The submitted documentation supports the requested services in this clinical setting. This patient has painful varicose veins and swelling, and her primary care provider has recommended evaluation with a vascular surgeon. Primary care providers may not be up-to-date on the appropriate compression to order for patients. Additionally, primary care providers may have difficulty with ultrasound interpretation. Based on this patients reported pain, a consultation with a vascular surgeon is medically appropriate. Therefore, the requested consultation with a vascular surgeon 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 general vascular 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: An enrollee has requested authorization and coverage for Northera. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. Northera is approved for the treatment of neurogenic orthostatic hypotension. The drug improves symptoms of orthostatic dizziness, lightheadedness and near-fainting. Although the records mentioned the diagnosis of orthostasis, the recorded blood pressures available for review did not demonstrate orthostasis. Autonomic function testing, which is the definitive test, did not show orthostasis. In sum, this patient does not have documented orthostatic hypotension or evidence of cardiovascular autonomic dysfunction. Therefore, Northera is not medically necessary 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Supartz injections one each knee. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Medical literature shows on a systematic review of meta-analyses comparing hyaluronic acid injections with other non-operative treatment modalities for knee osteoarthritis. The authors found that intraarticular hyaluronic acid improves knee pain and function. Researchers noted that the benefits of intraarticular hyaluronic acid on knee osteoarthritis may include mechanical viscosupplementation of the joint andthe re-establishment of joint homeostasis through induction of endogenous HA [hyaluronic acid] production, which continues long after the exogenous injection has left the joint. Moreover, hyaluronic acid injections have been shown to have a good safety profile. All told, the requested Supartz injections one each knee are medically necessary for treatment of this patients bilateral knee osteoarthritis. 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

The enrollees parent is requesting reimbursement for residential treatment center (RTC) level of care services. The enrollee has diagnoses of attention-deficit hyperactivity disorder, unspecified anxiety disorder, adjustment disorder with mixed disturbance of emotions and conduct, moderate cannabis use disorder, and parent-child relational problem. He had difficulty coping with his emotions and was reactive at times. Prior to his admission to the wilderness program, he was using marijuana daily and had tried other drugs. There were signs of heightened emotional stress, with periodic anxiety or brief depressive-like reactions. The enrollees parents reported his moods were unpredictable, which led to increasing defiance at home. His parents were concerned about his escalating drug use; especially marijuana. He entered the wilderness program. The enrollee participated in interventions and challenges specific to outdoor behavioral healthcare, designed to help him build skills related to self-confidence, assertive communication, interpersonal relationships and coping skill development. The enrollee learned and practiced dialectical behavioral therapy to develop skills focused on mindfulness, emotional regulation, distress tolerance and interpersonal effectiveness. He participated in a substance use-counseling program. He learned how to identify and manage his emotions in healthier ways. He learned basic cognitive therapy strategies designed to help him identify and replace the unhealthy thought patterns that reinforce his feelings of depression and anxiety. The enrollees mother states the enrollee had already exhausted several outpatient resources; including therapy and academic interventions. The Child and Adolescent Level of Care Utilization System (CALOCUS), developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations was utilized in this review. The enrollees composite CALOCUS score correlates with high intensity community-based services.Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and child and adolescent 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old male enrollee has requested Vyvanse, 80mg per day for treatment of his attention deficit/hyperactivity disorder.  Findings:  The physician reviewer found that the medical records provided by the treating physician note that that the patient has a short temper and is distracted at work.  Anxiety is also noted. The medical notes indicate that the patient has been on Lexapro for several years.  There is no documentation regarding Vyvanse or the need for the 80mg per day dose.  The recommended maximum dose of Vyvanse is 70mg per day. Both safety and efficacy have been studied within this dose range (Brown and colleagues and Weisler and colleagues).  Based upon the submitted documentation, the medical necessity of Vyvanse, 80mg per day, has not been established. All told, Vyvanse, 80mg per day, is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for heart procedure (electrophysiological study and catheter ablation) for treatment of the enrollees history of premature ventricular contractions. Findings:  The physician reviewer found the submitted documentation supports the medical necessity of the requested services.  The PVC ablation is medically necessary in this case. The medical studies show that frequent PVCs can be associated with a cardiomyopathy. Catheter ablation is considered if there is failure or intolerance to medical therapy, a single PVC morphology noted, and probable reversible left ventricular systolic dysfunction due to PVCs. These conditions are documented in this patient. The patient has symptoms of frequent palpitations due to premature ventricular complexes and palpitations were reported to occur several times a day. An EKG showed PVCs in a pattern of bigeminy. A Holter showed 18% of beats to be PVCs. His symptoms and arrhythmia persisted despite metoprolol. Catheter ablation is indicated for the PVC focus. As such, the heart procedure (electrophysiological study and catheter ablation) is medically necessary for the treatment of this patients medical condition. 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 internal medicine with sub-specialty certification in cardiovascular disease and clinical cardiac electrophysiology 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 nusinersen (Spinraza) for treatment of the enrollees spinal muscular atrophy (SMA). Findings:  The physician reviewer found that Spinraza is the first drug approved to treat pediatric and adult patients with spinal muscular atrophy (SMA). Spinraza is an antisense oligonucleotide that is designed to increase the expression of the survival motor neuron protein, which is deficient in patients with SMA. Although this patient has significant motor deficits from his SMA, he is able to perform activities of daily living (ADLs) with difficulties and is still working. Increasing the expression of motor neuron protein in the patients surviving motor neurons may improve or delay the progression of the patients motor deficit. Overall, the patient is still relatively functional and Spinraza may help the patient continue to perform ADLs and work. Thus, the requested Spinraza is supported as medically necessary for treatment of this patients SMA. 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 neurology with sub-specialty certification in neuromuscular 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 55-year-old female enrollee has requested intravenous (IV) Ketamine therapy for treatment of her thumb injury.  Findings:  The physician reviewer found that IV Ketamine therapy is not medically necessary for treatment of this patients chronic medical condition. There is a paucity of medical literature or double blind placebo controlled studies demonstrating the safety and effectiveness for the requested use. Schwartzman and colleagues performed a randomized double blind placebo controlled trial to evaluate the effectiveness of IV Ketamine in the treatment of complex regional pain syndrome. The study showed that IV Ketamine administered in an outpatient setting resulted in statistically significant reductions in many pain parameters. Overall, the results of the study warranted a larger randomized placebo controlled trial using higher doses of Ketamine for longer follow-up period. Correll and colleagues published a retrospective study to determine the utility of IV Ketamine in treating patients with complex regional pain syndrome. The retrospective study suggested that limited sub-anesthetic inpatient IV infusions of Ketamine may offer a promising therapeutic option in the treatment of appropriately selected patients with intractable complex regional pain syndrome. However, more studies are needed to further establish the safety and efficacy of this type of therapy. This patients chronic pain condition does not present in a way that supports an indication for IV Ketamine therapy. Therefore, the requested IV Ketamine is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation for evaluation of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation fails to support the requested services in this clinical setting. The patients provider had noted that TMS is appropriate if the patient had a failure to respond to several evidenced based augmentation therapies. However, there is no documentation that the patient received any augmentation therapies. He received monotherapy with sertraline, Effexor, Prozac, and Lexapro. The record does not show that this patient has been augmented with mirtazapine, lithium, bupropion, or thyroid hormone which are the augmentation medications. The patient is currently on lamotrigine 300 mg for the treatment of his depression. The provider also reported that the patient has major depressive disorder and not dysthymia or bipolar disorder. Lamotrigine for the treatment of unipolar depression is considered off label use. It is likely that the patient is receiving benefit from lamotrigine due to emotional dysregulation that could be from a personality disorder or unresolved trauma. The records do not support that this patient has been adequately trialed with depression augmentation strategies. As such, TMS therapy would not be clinically justified at this time until augmentation strategies for the treatment of this patients depression have been performed. 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 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

Nature of Statutory Criteria/Case Summary:An enrollee has requested authorization and coverage for Synvisc injection for treatment of the enrollees osteoarthritis.  Findings:  The physician reviewer found that the current medical evidence supports the medical necessity of the requested services. Evidence-based peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and is more effective than corticosteroid injections. In this case, the patient has been diagnosed with osteoarthritis of the left knee. He presents with recurrent left knee pain and swelling. Clinical examination findings have been consistent with reported radiographic evidence of moderate osteoarthritis of the left knee. Conservative treatment has included activity modification and anti-inflammatory medication, with inadequate relief. Prior Synvisc injections have provided at least six months of pain relief and reduction in medication use. 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.