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

A sixty-five year-old female with hip issues is requesting reimbursement for the CT scans. Reviewers Findings:  The reviewing physician found that CT scans of the pelvis and abdomen were medically necessary in this patient.  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 Mekinist and Tafinlar for treatment of the enrollees poorly differentiated adenocarcinoma with mixed neuroendocrine and acinar cell features.  Findings: Two physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested medications.  Mekinist is a new drug that has been approved for use in melanoma that has the BRAF V600E mutation.  It is often combined in such use with Tafinlar.  This combination is approved for use in BRAF V600E positive melanoma.  There have been studies of this combination or Mekinist alone, in other cancers that are also BRAF V600E mutation positive.  The results have been disappointing.  There is a lack of data available demonstrating usefulness of these drugs in pancreatic cancer.  It is becoming clear that a mutation alone does not select for efficacy; primary site plus the mutation appear to be important.  Thus, the presence of a BRAF mutation does not necessarily predict for response to Mekinist.  There is controversy as to whether at this point in time the results of molecular target analysis can be used to select therapy generally.  All told, Mekinist and Tafinlar are not likely to be of greater benefit than other treatment alternatives.Final Result: Two reviewers determined that the requested medications are 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 internal medicine with sub-specialty certification in medical oncology 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

A 58-year-old female enrollee has requested a Hyalgan injection series for the treatment of her osteoarthritis. Findings:  The physician reviewer found that although the efficacy of inter-articular injections of hyaluronic acid for the treatment of osteoarthritis of the knee is accepted, questions remain regarding the therapeutic benefits in some clinical situations. The value of a second series of injections has been shown to be of value, with no significant increase in adverse events. However, there is a lack of evidence of the efficacy of further courses of therapy, and there is some evidence of increasing problems with additional injections.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for a Flexitouch pneumatic compression device (PCD) and garments. Intermittent pneumatic compression (IPC), also called sequential pneumatic compression, is a method of compression therapy. Blumberg and colleagues report that pneumatic compression is well tolerated by patients and should be recommended as an adjunct to standard lymphedema therapy. Desai and colleagues note that pneumatic compression therapy leads to improved clinical outcomes, quality of life, and functional status for clinically significant lymphedema. In this case, the patient has lymphedema and had failed other therapies. Given that current medical literature supports the use of the requested equipment in this clinical setting, the requested equipment is medically indicated. Therefore, a Flexitouch PCD and garments are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 71-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of her depression.  Findings:  The physician reviewer found that based on review of the available records, the patient is enduring an acute, recurrent major depressive episode that is causing significant morbidity and functional impairment. She has pursued, but not exhausted other standard therapies used to treat her depression. However, her provider articulates the rationale supporting TMS therapy as the best treatment option for this specific case. Considering the endorsement from the American Psychiatric Association (APA) for the acute phase treatment of unilateral depression and the expanding peer-reviewed literature base, TMS is a safe and reasonable intervention to treat this patients major depressive disorder at this particular stage of her illness. Thus, TMS treatment was and is medically necessary from the date in question and forward for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for oxycodone HCL 10 mg tablets, three times per day for treatment of the enrollees pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. The patient is requesting coverage for oxycodone HCL 10 mg tablets, three times per day. The formulary alternatives include oxycodone-acetaminophen tablets, which is the same drug in a different formulation (immediate release). The immediate release tablets can be dosed every four hours to produce the same effect as the extended release. Additionally, there were no urine toxicology results included in the records submitted.  There is a lack of support for the requested medication in this clinical setting.  All told, oxycodone HCL 10 mg tablets, three times per day 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old male enrollee has requested Xanax, at a dose between 3.5mg per day to 7mg per day, and Klonopin, at a dose between 1.5mg per day and 3mg per day for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications.  In the early 1960s, the newly synthesized benzodiazepine class of medication effectively supplanted barbiturates as the mainstay of psychopharmacologic treatment of anxiety.  However, benzodiazepines carry the risk of tolerance and dependence.  In this patients case, the records indicate benzodiazepine dependence.   Xanax (alprazolam) is highly addictive.  The medication may be indicated for the treatment of panic disorder when it can be utilized as an occasional rescue medication as part of a comprehensive plan that would typically include cognitive behavioral therapy and a non-addictive daily serotonergic enhancing medication aimed at decompressing the global anxiety titer.  In this case, there is no evidence of panic disorder and there is concern of misuse of this medication.  This medication is potentially harmful in this patients case and is not medically necessary.  Klonopin (clonazepam) is a longer acting benzodiazepine and reasonable for tapering purposes.  In general, routine prescription of two different medications from the same potentially addictive class is inconsistent with good medical practice.  Regarding this patients case, the documentation provided does not support the medical necessity for either Xanax or Klonopin for the treatment of a mental health condition.  The Health Plans recommendation for a taper regimen is medically appropriate.  All told, Xanax, at a dose between 3.5mg per day to 7mg per day, and Klonopin, at a dose between 1.5mg per day and 3mg per day are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Stelara 90 mg/mL. Findings:  The physician reviewer found that the current literature suggests that Stelara is safe and may have long-term efficacy for patients with moderate to severe arthritis. However, there are no guidelines to recommend one biologic over another for use in this clinical setting. In this case, the records document that the patient has been treated with one non-steroidal anti-inflammatory drug (NSAID) for therapy. He is noted to be unable to take methotrexate due to increased liver function tests (LFTs) with documentation of an elevated alanine aminotransferase (ALT) of 65. Overall, the medical records fail to demonstrate that the patient has persistently elevated LFTs, which would support a contraindication for methotrexate. The provider did not include documentation that the patient has been treated with and failed an adequate trial of sulfasalazine, cyclosporine, leflunomide, or Otezla. Moreover, there has been no trial of a tumor necrosis factor inhibitor. Although patients taking tumor necrosis factor inhibitors are at increased risk of contracting coccidiomycosis, according to the U.S. Food and Drug Administration (FDA), only current invasive fungal infections are contraindicated. Residence in an endemic area is not considered a contraindication to treatment with a tumor necrosis factor inhibitor. For these reasons, the request for Stelara 90 mg/mL is not medically necessary for treatment of this patients psoriatic arthritis and psoriasisFinal 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 rheumatology 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 Forteo for treatment of his osteoporosis with compression fracture.  The physician reviewer found that review of the submitted documentation establishes the medical necessity of the requested medication. Forteo is indicated for patients with osteoporosis at high risk for fracture. In this case, the patient presents with multiple vertebral fractures. Given the patients multiple vertebral fractures, he is at high risk for future fractures of the spine. In this case, the patient has fragility fractures and anabolic therapy is clinically indicated. Based on the clinical documentation submitted for review, Forteo 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 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: Experimental/Investigational
Decision: Overturned

A female enrollee requested Botox injections for medical treatment of her chronic migraines. Findings:  Two physician reviewers found that Botox injections are likely to be more effective for this patient than other available options. This patient has a 10-year history of migraines with significant worsening in the last two years. She has been treated with Botox injections, which has provided a substantial reduction in migraine and headache frequency. The patient reports a marked reduction in severity and reduction in disability. In addition, Botox is U.S. Food and Drug Administration (FDA) approved for the treatment of chronic migraine. For the reasons provided, Botox injections are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Sovaldi for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated, except those with life expectancy less than 12 months due to non-liver-related conditions.  This applies regardless of fibrosis stage.  Per the guidelines, for treatment-naive, genotype 2 patients, therapy is recommended with Sovaldi/Daklinza or Epclusa.  Sovaldi and ribavirin are no longer recommended.  The guidelines cite data showing that delay in treatment may result in decreased survival.   Final Result: The reviewers 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. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld

A 34-year-old female enrollee has requested for emergency services for treatment of herdifficulty, frequency, and pain with urination. Findings:  The physician reviewer found that the prudent layperson standard for an emergency requires that the patients condition be of acute onset and of such severity that a prudent layperson would believe her health to be in jeopardy without immediate medical attention. The patient had no signs of systemic toxicity and could have been safely treated as an outpatient. The duration of the Emergency Department visit was very short, and the patient was in stable condition throughout the entire visit.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old male enrollee has requested residential treatment for treatment of the enrollees depression. Findings:  The physician reviewer found that this patient was admitted to a residential treatment center after a suicide attempt.   He has a history of abusing several different drugs and had been to substance abuse inpatient treatment multiple times in the past.  These treatments do not appear to have had a significant effect on the patients substance problems.  The most concerning factor in this case is the fact that the patient has auditory hallucinations when not using substances.  His outpatient provider believed that he may be suffering from early onset schizophrenia.  The patient had a flat affect during much of his time at the residential treatment center and displayed constant poor judgment.  In cases such as this, an evidence-based, objective, instrument such as the Child and Adolescent Level of Care Utilization System is indispensable in determining the necessary level of care for children and to insure the level of care meets individual needs in the least restrictive setting possible. Per these guidelines, non-secure, 24-hour psychiatric monitoring was indicated at the time of admission. This indicates that he met criteria for a residential treatment center stay at the time of admission. Since his progress in treatment as of his discharge date was minimal, it appears that he continued to meet criteria for residential treatment center placement.  He also has a history of failed treatments in the past at an inpatient level of care. The American Academy of Child and Adolescent Psychiatry recommends that children and adolescents be treated in the least restrictive setting possible.  In this patients case, the residential treatment center level of care was the least restrictive setting needed to treat this patient.  Thus, residential treatment provided during the time period at issue was 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 Vemlidy. Findings:  The physician reviewer found that Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), which the patient is taking, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease . For this reason, the requested Vemlidy is supported as medically necessary for the treatment of this patients chronic hepatitis B. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Tylenol with codeine for treatment of her chronic pain and headaches. The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for Tylenol with codeine has not been established. According to Argoff and Silvershein Management of chronic noncancer pain (CNCP) requires a comprehensive assessment of the patient, the institution of a structured treatment regimen, an ongoing reassessment of the painful condition and its response to therapy, and a continual appraisal of the patient's adherence to treatment. In this case, the patient presents with liver disease, chronic pain and migraines with multiple drug screens showing the patient tested positive for marijuana. According to Weatherall, Many patients with chronic migraine also have medication overuse, defined as using a compound analgesic, opioid, triptan or ergot derivative on at least 10 days per month. Given the patients liver disease and positive drug screens the requested Tylenol with codeine is not medically necessary in this clinical setting. 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcatheter aortic valve replacement (TAVR). Based on the records provided for review, this patient has critical aortic valve stenosis with new symptoms likely related to stenosis. In addition, the patient was found to have high risk echocardiogram features with a peak gradient greater than 100 mmHg. In this clinical setting of symptomatic critical aortic valve stenosis, the requested TAVR is reasonable according to the current American College of Cardiology (ACC) and American Heart Association (AHA) guidelines (Nishimura, et al.; Otto, et al.). Per the ACC/AHA guidelines, The decision to intervene, as well as the type of procedure recommended, is based on an assessment of patient-, procedure-, and institution- or operator-specific short-term risks and long-term benefits. Given this patients symptomatic critical aortic valve stenosis, intervention with TAVR is appropriate and consistent with the ACC/AHA guidelines. Therefore, the requested TAVR is medically necessary for 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 internal medicine with subspecialty certifications in cardiovascular disease and adult congenital heart disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee requested authorization and coverage of the medication Actiq. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees pain.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.