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

A 52-year-old female enrollee has requested the compound medication Mustargen for treatment of her diagnoses with mycosis fungoides stage IB. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication.  This patient has requested coverage for topical nitrogen mustard (Mustargen) for treatment of mycosis fungoides, which is a rare form of cutaneous T-cell lymphoma.  She responded well in the past to this established and proven therapy for mycosis fungoides.  Skin-directed therapy with Mustargen has been shown to be safe and effective for early stage disease.  All told, the compound medication Mustargen is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested reimbursement for posaconazole 300 mg by mouth daily for 30 days. This patient has a history of cough, shortness of breath, rhinitis, and chronic maxillary sinusitis. Posaconazole is reserved for invasive fungal sinusitis, which generally occurs in severely immunocompromised patients. The medical literature does not support the use of posaconazole for patients with mild CT findings and no invasive fungal disease. Rare fungal elements are normal on sinus cultures and are found in over 90% of patients when the culture is properly performed, and this does not require treatment with posaconazole. All told, the posaconazole 300 mg by mouth daily for 30 days, was not medically necessary for treatment of this patient.Final Result: The reviewer determined that the medication at issue was 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 otolaryngology 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

A 28-year-old female enrollee has requested for a Melody pulmonary valve replacement via catheter for treatment of his pulmonary regurgitation. Findings:  Three physician reviewers found that there have been clinical trials examining the use of transcatheter pulmonary valve replacement as an alternative to open heart surgery. The peer reviewed medical literature has demonstrated that this procedure has been found to be beneficial at one year in follow-up studies, with minimal complications. Although there is a paucity of long-term follow-up data with use of the Melody valve replacement procedure via catheterization, there is less chance of complication during the procedure than with a standard surgical re-intervention. Thus, the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 23-year-old female enrollee has requested for acute inpatient psychiatric services for treatment of the her depression and substance abuse.   Findings:  The physician reviewer found that the patient told her outpatient psychiatrist that she was suicidal and restated that she was suicidal and told of a plan to overdose on aspirin the previous night, while in the ED. She was abusing cocaine at the time, and may have had depression secondary to her substance abuse. Withdrawal from cocaine does often cause or exacerbate depression. The patients inpatient evaluation appropriately included a substance abuse consultation with a recommendation to attend a CD IOP.  Step down to a CD IOP was appropriate at that point in time.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female enrollee requested ligation of perforator veins (CPT 37761), stab phlebectomy (CPT 37765), and injection of sclerosing agent (CPT 36471) for treatment of her varicose veins. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services.  This patient has a variant of the common form of venous insufficiency, with her provider documenting reflux from a thigh perforator.  In this clinical setting, it is appropriate to treat the varicose veins that are causing the symptoms, either by phlebectomy or with sclerotherapy.  However, the current literature does not support treatment of an underlying perforator vein that is refluxing.  In this patients case, the phlebectomies and removal of the branches are medically necessary.  However, the treatment of the perforator, whether by ablation with heat or sclerotherapy, is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Technivie (ombitasvir-paritaprevir-ritonavir 12.5 mg/75 mg/50 mg) tablets for 12 weeks. Findings:  The physician reviewer found that : According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 4 patients should be treated with Technivie and ribavirin for 12 weeks. However, this is recommended as an alternate regimen rather than first-line therapy. This guideline recommendation is based on the PEARL-1 trial, which demonstrated a 100% cure rate in this population . AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment . As there is no documented plan to use ribavirin, the requested treatment with Technivie for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection. Additionally, the AASLD/IDSA guidelines recommend the use of the Health Plans preferred medication, Harvoni, as first-line therapy. The documentation does not support a contraindication to Harvoni.  For these reasons, Technivie (ombitasvir-paritaprevir-ritonavir 12.5 mg/75 mg/50 mg) tablets for 12 weeks is not medically necessary for treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication regimen is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested UVB light therapy for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  Photochemotherapy refers to the combination of psoralen and UVA light.  This is a different treatment regimen than narrowband UVB, which is what this patient is requesting.  Per the medical records, this patient is doing well with her current phototherapy treatments.  The medical evidence supports the requested services in this clinical setting.  All told, the requested UVB light therapy is medically indicated 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 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: Overturned

A 62-year-old male enrollee has requested hand-held UVB light (Dermalume 2x) for treatment of his vitiligo.  Findings:  Two physician reviewers found that Vitiligo is a skin disorder in which there is a loss of pigmentation of the skin.  The current medical literature supports narrowband UVB phototherapy either alone or in combination with other therapies for the treatment of vitiligo.  Narrowband UVB therapy can be provided in full body phototherapy units, in the Excimer laser, and in home units, and the safety of narrowband UVB has been well-established in all three forms.  More frequent treatments demonstrate superior efficacy in the treatment of vitiligo.  This patient has been treated with optimal therapies and is followed closely by his dermatologist.  All told, the requested hand-held UVB light (Dermalume 2x) is likely to be of greater benefit than other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee requested authorization and coverage of skilled nursing facility (SNF) services for four months after planned rotator cuff surgery.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cervical spine magnetic resonance imaging (MRI) (neck). The American College of Radiology (ACR) appropriateness criteria for the evaluation of new or increasing nontraumatic cervical radiculopathy note that MRI of the cervical spine is considered usually appropriate. An MRI is currently the preferred modality to evaluate the cervical spine in the setting of nerve root impingement. Kuijper and colleagues report that MRI findings in patients with cervical radiculopathy should be interpreted together with the clinical findings. In this case, the previous MRIs demonstrated multilevel degenerative changes. Given that the patient reports a recent increase in symptoms and radiculopathy, and as a repeat MRI of the cervical spine is necessary prior to intervention, the requested service is medically indicated. Therefore, cervical spine MRI (neck) is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 parents of an eight-year-old male with apraxia of speech are requesting coverage of SPECT scan and doppler vasodilators.  Reviewers Findings:  The reviewing physician found that SPECT scans and vasodilators are not standard treatment for apraxia of speech or developmental delay.  The Health Plan denial was upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for ondansetron 4 mg, 90 tablets per month. Ondansetron is U.S. Food and Drug Administration (FDA) approved for the prevention of nausea and vomiting associated with chemotherapy, post-operative nausea and/or vomiting or radiotherapy-associated nausea and vomiting. Current medical literature supports a clinical role for ondansetron for the treatment of nausea and vomiting. Dosing for the treatment of nausea and vomiting due to other medical conditions that are self-limiting is 4 mg as a single dose. In this case, the documentation supports that the use of ondansetron is for nausea and vomiting related to the use of metformin to treat the patients medical condition of diabetes mellitus. The treatment of nausea related to the use of metformin is to decrease the dose of metformin or take a break from the medication. Overall, ondansetron to treat the side effect of nausea related to the use of metformin is not medically necessary. Furthermore, the requested ondansetron 4 mg, 90 tablets per month, exceeds the recommended dose of 4 mg one time for nausea and vomiting in this clinical setting. All told, the requested ondansetron 4 mg, 90 tablets per month, is not medically necessary for 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 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 70-year-old male enrollee has requested continuation of hospice care while receiving chemotherapy for treatment of his medical condition. Findings:  The physician reviewer found that the literature certainly suggests that palliative chemotherapy is an option for patients who have stage IV non-small cell lung carcinoma. In this case, the records reflect that the patient desires to continue aggressive therapy and therefore palliative chemotherapy was ordered. However, since this patient wishes to continue to pursue such treatment, he is not appropriate for hospice care at this time. The patients decision to continue to receive chemotherapy is not consistent with acceptance of mortality and thus does not demonstrate readiness for end-of-life care. Further, given the need to continue to monitor his response to treatment with labs and imaging, the services provided by hospice care are not medically appropriate for this patient. All told, the submitted evidence demonstrates that the patient is not ready to receive end-of-life care, and therefore, hospice care is not medically necessary at this time. If the patient decides that chemotherapy is no longer desired, or that it can no longer be tolerated, hospice care would then be medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 56-year-old male with mixed hyperlipidemia, glucose intolerance and obesity.  Meridia was prescribed for weight loss in January 2006. At that time, the patient was 511 tall and weighed 240 pounds with a calculated body mass index (BMI) of 33.5. The patient paid out of pocket for Meridia, and lost 11 pounds after taking the medication for approximately six weeks. His request for reimbursement and continuing authorization of Meridia was denied by the Health Plan based upon a determination that the medication is not medically necessary.The medical records provided do not demonstrate that the patient has a BMI greater than 35 as indicated in the criteria for the usage of Meridia. His associated comorbidities are conditions that will affect his general health and well-being, but do not necessitate the use of Meridia. Therefore, I have determined the medication at issue was/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 Rituximab (Rituxan).Findings:  The physician reviewer found that this patient did not tolerate treatment with prednisone and cyclosporin due to side effects. Given the support in the medical literature, the requested Rituxan 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 subspecialty certification in nephrology 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 is a 44-year-old female who has requested authorization and coverage for the medication Allegra. The patient has a history of allergic rhinitis, asthma, and recurrent sinusitis. The patients provider notes the patient has tried and failed numerous medications for treatment of her allergic rhinitis including Claritin, Actifed, Clarinex, Zyrtec, Sudafed, and Phenergan. The Health Plan has denied coverage for Allegra indicating that the requested medication is not medically necessary for treatment of the patients medical condition. No objective documentation has been provided demonstrating that Allegra is medically necessary at this time. The patient has chronic rhinitis despite use of antihistamines, intranasal steroids, and Singulair. As such, an allergy referral for consideration of immunotherapy or other medical treatment alternatives is medically indicated. There is no evidence that another antihistamine would prove any more efficacious than those previously tried. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested stem cell breast reconstruction (cell-assisted lipotransfer (CAL) technique) for both breasts for treatment of the enrollees carcinoma in situ. The physician reviewer found that the American Society of Plastic Surgeons (ASPS) and American Society for Aesthetic Plastic Surgery (ASAPS) noted that until further evidence is available, stem cell therapies in aesthetic and reconstructive surgery should be conducted within clinical studies under Institutional Review Board approval, including compliance with all guidelines for human medical studies. Paik and colleagues concluded that, although these cells may have great promise as a cellular therapy in a variety of settings, we must continue to probe their complex roles as a stem cell population to make full use of their clinical potential. Overall, although stem cell assisted lipotransfer may provide benefit its use has not been shown to replace traditional fat transfer in this clinical setting, which is considered the standard of care. Given these findings, the requested stem cell breast reconstruction CAL technique for both breasts is not medically necessary. The patient has a documented right breast deformity secondary to lumpectomy followed by radiation therapy. The patient has a well-defined defect secondary to the right breast following oncologic treatment. The defect on the left side is not well-defined. Although the patient has a well-defined abnormal appearance of the right breast resulting from oncologic treatment, its proposed correction with stem cell using the CAL technique would not be expected to create more than a minimal improvement in the abnormal appearance. Accordingly, the requested stem cell breast reconstruction CAL technique for both breasts is not reconstructive in nature. Thus, the requested stem cell breast reconstruction CAL technique for both breasts is not reconstructive in nature and not medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the requested services are not reconstructive in nature and 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 plastic 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

A fifty-three year-old female with arthritis involving both knees is requesting for authorization of Synvisc injections.  Reviewers Findings:  The reviewing physician found that this therapy can reasonably be expected to alleviate the pain and postpone the need for surgical intervention.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Combigan 0.2% - 0.5% drops. Findings:  The physician reviewer found that Combigan is a combination of timolol 0.5% and brimonidine 0.2%. The main advantage of the using combination drop is the convenience since the same IOP lowering effect can be achieved with using the same medication (timolol and brimonidine) as single agents. The standard practice would be to prescribe timolol and brimonidine as separate drops. Alternatively, there are other combination drops that are covered by the Health Plan (Cosopt or Simbrinza) which could also be used instead with similar efficacy. The documentation provided did not indicate an intolerance to the drops that are covered by the Health Plan. Final Result: Two of the three physician reviewers determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: all three physician reviewers are board certified in ophthalmology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and are 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

A 50-year-old female enrollee has requested for Actiq 1600mcg for treatment of her cervical pain. Findings:  The physician reviewer found that there is more experience with the use of opioids in the cancer population, and the long-term use and continuous efficacy of these medications in the non-malignant pain population is still a matter of debate. Even though the etiology of pain in these two separate populations seems to be fairly distinct, the actual experience of pain itself cannot be clearly separated. Moreover, long acting opioids seem to be a more reasonable alternative than around-the- clock short acting preparations.