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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) and partial hospitalization program (PHP) services. Per the American Society of Addiction Medicine (ASAM) treatment criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services such as RTC level of care. ASAM criteria note that not all social and psychological problems will be resolved in the Level 3.5 treatment stay. Such complex and often lifelong challenges will need an ongoing treatment process to enhance wellness and recovery. Thus, the treatment in Level 3.5 is best viewed as just one part of a persons treatment and recovery process seamlessly integrated into a flexible continuum of services. ASAM includes six dimensions to determine the appropriate level of care for adults. For dimension 1, intoxication and withdrawal potential, this patient has a history of medical withdrawal from alcohol and Ambien. Dimension 2 considers a patients biomedical conditions. This patients records do not report any biomedical conditions. For dimension 3, emotional, behavioral, cognitive conditions, the patient has comorbid anxiety leading him to use to cope with stress. Dimension 4 evaluates a patients readiness to change. This patient is noted to be in the preparation stage toward making substantial changes. For dimension 5, relapse and continued use problem potential, the patients history is positive for continued use despite negative consequences. Currently, the patient has underdeveloped coping skills and plans in place to prevent relapse. For dimension 6, recovery environment, the patients work pressure is related to his substance use. Further, the patient has a tendency to filter information to protect others, which leaves him isolated and not seeking support from his recovery environment. Given the severity of the patients illness, RTC and PHP were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 psychiatry with expertise in addiction 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lyrica (pregabalin) for treatment of the enrollee, who has history of joint and muscle pain. Findings:  The physician reviewer found that studies have shown that neuropathic pain varies in its severity and its effect on patients. Chronic pain that is unable to be cured can be considered palliative in nature and treatment. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting.  In this patients case, not all treatment options were noted to have been utilized. The submitted records do not show that this patient has participated in behavior therapy despite much research supporting its use. The medical evidence supports that prior to prescribing controlled substances, certain criteria need to be met. In this patients case, multiple minimal requirements for controlled substance prescribing have not been performed. In addition, the submitted records do not show that other non-opioid medications classes have been optimized or tried. As such, the medical necessity of the requested medication as a primary treatment strategy has not been established. For all these reasons, Lyrica (pregabalin) is not medically necessary for treatment of this patients medical condition. 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 51-year-old male enrollee has requested growth hormone therapy for treatment of chronic pain and fatigue.  Findings:  The physician reviewer found that there is insufficient peer-reviewed data to support the utilization of growth hormone therapy to manage chronic pain syndrome. Furthermore, the use of growth hormone for the management of chronic pain syndrome is not within generally accepted medical management guidelines and does not meet standards of care. There are other available modalities for management of this patients chronic pain and fatigue.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for the medication Lyrica . The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition.Lyrica is not indicated for rheumatoid arthritis (RA) or other autoimmune diseases. An article noted the options for patients with inflammatory arthritis and fibromyalgia and found no randomized trials that support the use of Lyrica; rather its use is empiric and not evidence based for RA with widespread muscle pain. The requested medication is not medically reasonable or necessary.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 subspecialty certification in pain management, 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. Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for LINX Reflux Management System procedure. The LINX device received U.S. Food and Drug Administration (FDA) approval for patients with diagnosed GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximal medical therapy for the treatment of reflux. Although there is a need for comparative studies, available data suggests that LINX may provide long-term benefit in well-selected patients. Appropriate patient selection is crucial before anti-reflux procedures. Currently, upper endoscopy, barium esophagram, pH testing, and manometry are required for preoperative workup for antireflux surgery. This patient has GERD as based on pH recording. However, the records document adequate management of GERD when he is compliant with taking acid blocker drugs. Since this patient can optimize the benefit from available standard therapy by optimizing compliance with daily Dexilant use as well as a lifestyle aimed at GERD prevention, the requested procedure is not indicated. Therefore, the LINX Reflux Management System procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested services 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:  One reviewer is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing.  All three 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi for 24 weeks for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that according to the most recent guidelines issued, 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 or viral load. Per guidelines, the alternative regimen for genotype 3 interferon-ineligible patients is daily sofosbuvir and weight-based ribavirin for 24 weeks. More recently, AASLD/IDSA recommendations for treatment of patients in this clinical setting has shifted to the following: for treatment-naive patients with HCV genotype 3 infection the recommended regimen is daily daclatasvir and sofosbuvir for 12 weeks (no cirrhosis) or 24 weeks with or without weight-based ribavirin (cirrhosis) or daily sofosbuvir and weight-based ribavirin plus weekly peginterferon for 12 weeks is recommended for interferon-eligible patients. In the absence of demonstrated interferon-ineligibility or intolerance to daclatasvir, the 24-week course of Sovaldi treatment is not the highest-rated brief-duration option recommended by AASLD/IDSA, and thus is not medically necessary. For the reasons provided, the requested medication is not medically necessary for treatment of the patients medical condition.  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 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: The patient has requested authorization and coverage for Aimovig 140 mg. Findings: Calcitonin gene-related peptide receptor antagonists (CGRP) are biologic agents with demonstrated efficacy, safety, and tolerability for the preventive treatment of episodic and chronic migraine that do not require dose titration, may achieve rapid treatment effects, and are effective in patients who have failed prior preventive treatment and in patients on concurrent oral preventive treatments. Aimovig (erenumab) is a CGRP approved by the U.S. Food and Drug Administration (FDA) for the preventive treatment of migraine in adults.  The American Headache Society (AHS) notes that treatment with monoclonal antibodies to CGRP may be indicated for patients with chronic migraines with an inadequate response to topiramate, Depakote, metoprolol, and nortriptyline. A study found that in patients with chronic migraines, erenumab 70 mg and 140 mg reduced the number of monthly migraine days with a safety profile similar to placebo. Another study reports that erenumab 140 mg monthly may be preferred over the 70 mg monthly dose in patients with episodic migraine or chronic migraine and prior preventive treatment failures. In this case, the patient has a history of chronic headaches and has not responded to multiple oral preventative medications. Given that the patient fits AHS criteria for treatment with CGRP monoclonal antibody therapy, the requested medication is medically indicated. Therefore, Aimovig 140 mg is medically necessary for the 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 neurology 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 forty-seven year-old female with multi-level lumbar disc disease is requesting authorization of an X-Stop decompression procedure.  Reviewers Findings:The reviewing physician found that this patient has multi-level disc disease, which would be a contraindication to the use of the X-Stop device.  The physician concluded that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 47-year-old female enrollee has requested Botox injections.  for treatment of her post-traumatic headache and neck and face pain.  Findings:  Three physician reviewers found that trigeminal neuralgia is a neuropathic disorder characterized by episodes of intense pain in the face, originating from one of the branches of the trigeminal nerve. Carbamezapine and oxcarbazepine are first-line treatments. For patients with medically refractory trigeminal neuralgia, gamma knife or microvascular decompression can be considered.  Botox has been the subject of small, non-randomized trials for treatment of trigeminal neuralgia.  However, large, randomized clinical trials with long-term follow-up are required to demonstrate that Botox provides health benefits, to define the clinical role of botulinum toxin, and to establish patient selection criteria.  Ho and colleagues published a systematic review of the literature regarding the use of Botox for the treatment of myofascial pain. The authors concluded that the current evidence does not support the use of Botox injections for treatment of myofascial pain.  Botox injections were not and are not likely to be the most beneficial treatment for this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old female enrollee has requested ABS disc decompression for the treatment of her back pain. Findings:  Three physician reviewers found that chiropractic vertebral disc decompression is generally considered an investigational/experimental treatment modality for disorders of the lumbar spine. There is little and insufficient peer-reviewed literature and no randomized controlled trials reporting on the safety and efficacy of vertebral disc decompression therapy compared to standard medical and surgical management options. Vertebral disc decompression therapy is not likely to be more beneficial than standard management options in this case.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 8-year-old female enrollee requested applied behavioral analysis (ABA) services for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. Based on the documentation submitted for review, a diagnosis of ASD has not been established. In this patients case, she has current diagnoses of mixed receptive-expressive language disorder, ADHD and anxiety disorder. Confirmatory evidence of a current diagnosis of ASD is lacking. In the absence of evidence of a recent evaluation confirming a diagnosis of ASD, the request for ABA services is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 13-year-old male enrollee has requested the prescription medication Provigil for treatment of the enrollees attention-deficit hyperactivity disorder.  Findings:  The physician reviewer found that although the current literature does suggest some degree of efficacy for Provigil in the treatment of ADHD, it is not yet an FDA approved indication. As such, the failure of all standard treatments should be plainly demonstrated before a non-standard treatment approach is adopted. In this instance, the records provided do not clearly show that the patient cannot tolerate the conventional drugs approved for the treatment of ADHD. In fact, it appears he did have some favorable responses to them.
Appeal type: Medical Necessity
Decision: Overturned

A 32-year-old female enrollee has requested BRCA testing (CPT codes 81211 and 81213) for evaluation of her family history of ovarian cancer.  Findings:  The physician reviewer found that BRCA testing is important in clinical oncology because bilateral mastectomy would eliminate a carriers chance of developing breast cancer. Likewise, closer surveillance for ovarian cancer can be applied or the patient may choose salpingo-oophorectomy, which would reduce the probability of developing this cancer. At the present time, genetic testing is not applied universally but rather to patients that exhibit family histories that are suggestive of inherited predispositions. A large study by Frank and colleagues performed BRCA testing in 10,000 patients and related the presence of mutations to the family history. The authors found that family history included at least one first or second degree relative with breast or ovarian cancer. In addition, the Milliman Guidelines state the patient must have a first or second degree relative with breast or ovarian cancer diagnosed at any age to support an indication for testing. Based on these criteria, the requested BRCA testing is medically necessary for evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 39-year-old female enrollee has requested a magnetic resonance imaging (MRI) of the breasts for evaluation of her bilateral enhancing diffuse foci. Findings:  Three physician reviewers found that applying the National Cancer Institute (NCI) Risk Assessment Tool, this patient qualifies for screening with MRI at this time. This determination is based on the patients family history in addition to her documented dense breast tissue, which limits the sensitivity of mammography. Further, the recommendation for a breast MRI is also consistent with Saslow and colleagues discussion of the American Cancer Society (ACS) guidelines. This patient had a screening MRI that revealed some abnormality classified as BIRAD 3. The non-mass like enhancement was only seen on the MRI exam and since these findings are specific to MRI (i.e. cannot be assessed with mammography or ultrasound), it is reasonable to repeat this study within a short interval as advised by the interpreting radiologist. The study is likely to provide unique data in analyzing this patients risk for breast cancer, and therefore is not investigational.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old female enrollee has requested a total abdominal hysterectomy and bilateral salpingoophorectomy for the treatment of her medical condition. Findings:  The physician reviewer found that this patient had heavy vaginal bleeding, anemia and she had a 16-week size uterus. Her symptoms recurred despite treatment with progesterone and NSAIDs. Her exam was consistent with fibroids and adenomyosis. Hysterectomy was medically necessary due to a markedly enlarged uterus and heavy bleeding. The pathology retrospectively confirms the need for hysterectomy (markedly enlarged uterus with fibroids, polyps, and adenomyosis). The patients post-operative care was routine and was also medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni plus ribavirin for treatment of his hepatitis C virus. 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 nonliver-related conditions. The guidelines recommend that patients who have failed therapy with an NS5A inhibitor (such as Viekira Pak) should undergo testing for resistance-associated variants.  In cases with lack of NS5A resistance, such as this one, the guidelines recommend re-treatment with Harvoni and ribavirin for 24 weeks.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni and ribavirin is supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The physician reviewer is 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: The patient has requested authorization and coverage for Repatha SureClick. Findings: In this case, the patient had multivessel, moderate coronary artery disease but was asymptomatic. Their low-density lipoprotein (LDL) level was not at goal despite maximum doses of rosuvastin and ezetimibe. The patient reported significant side effects to atorvastatin and continued to have mild myalgias on high dose rosuvastatin. While proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors are mainly used in patients with active coronary artery disease or prior events, they may reasonably be indicated in a patient with underlying significant but subclinical multivessel disease who is unable to tolerate conventional maximal statin/ezetimibe therapy or does not reach LDL goals on maximal oral therapy. In this case, the patient underwent a six-month trial of maximal dose rosuvastatin and ezetimibe therapy without reaching their LDL goal, and has known, established coronary artery disease. In this clinical setting, the requested medication is medically indicated. Therefore, Repatha SureClick is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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.