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 (1) Orthovisc injection series in the left knee and (2) Orthovisc injection series in the right knee. Findings: Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from prior injection series. The patient has tried and failed other conservative treatments including NSAIDs, corticosteroid injections, and physical therapy. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, (1) Orthovisc injection series in the left knee and (2) Orthovisc injection series in the right knee was and is medically necessary for the 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 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: Overturned

A 44-year-old female enrollee requested inpatient mental health services for medical treatment of her schizoaffective disorder. Findings:  The physician reviewer found thatthe submitted documentation supports the medical necessity of a portion of the services at issue.  This patient evidenced profound psychiatric symptomatologies in the context of acute marital discord upon admission.  Subsequently, nursing reported appropriate behavior, communication, mood and affect.  The patient was adherent with treatment.  The records indicated that her pain was less and her mood was better.  The mental status examination noted pleasant affect and the absence of suicidality, homicidal ideation and psychosis.  All told, initial inpatient mental health services were medically necessary.  However, the records fail to demonstrate the medical necessity of subsequent inpatient mental health services.  I have determined that a portion of the services was medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee requested authorization and coverage of an endoscopic discectomy for the treatment of severe pain  and disfunction due to a disc fragment floating in her spinal column.  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: Experimental/Investigational
Decision: Overturned

A 57-year-old female enrollee has requested Botox injections for the treatment of her writers cramp. Findings:  Two physician reviewers found that this patient has tried several different modalities for treatment of her writers cramp. Nonetheless, her symptoms have progressed to the point that they have interfered with her work. Botox is an effective treatment for focal dystonia whereas no other treatments are known to be helpful. In light of the patients history and condition, Botox injections are clearly the best treatment available.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi and Daklinza for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that according to 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. Patients with cirrhosis are considered to be highest priority for therapy. In cirrhotic treatment-naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 24 weeks. This is based on the ALLY-3 study, which showed a cure rate of 90%. Per the guidelines, only interferon-eligible patients can be treated with Sovaldi, peginterferon, and ribavirin. This patient is interferon-ineligible due to a pre-existing medical condition. Delay in treatment may result in decreased survival. For these reasons, the requested treatment with Sovaldi and Daklinza is 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 reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 58-year-old female enrollee has requested The Vest Airway Clearance System (Vest) for the treatment of her bronchiectasis. Findings:  Three physician reviewers found that the patient is a 58-year-old female with a diagnosis of bronchiectasis confirmed by CT scan. Her pulmonary function is well-preserved. However, the patient has recurrent respiratory infections and has trouble raising secretions. Oscillatory devices have not worked. The patient has established bronchiectasis, and she needs additional help to clear secretions. The Vest Airway Clearance System does help patients with bronchiectasis and is medically indicated and appropriate in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage of Harvoni 90-400 mg for 12 weeks for treatment of the enrollees 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 all patients should be treated, regardless of fibrosis stage. The patient should be considered treatment-naive due to failure of interferon with ribavirin rather than PEG-interferon with ribavirin; the guidelines specify that failure of PEG-interferon is required to be considered treatment-experienced. The guidelines recommend that treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic Hepatitis C Genotype 1 regardless of fibrosis stage.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  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: Physician reviewer number one 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

A 57-year-old female enrollee has requested for bilateral bunionectomy procedures for treatment of her bilateral bunions. Findings:  The physician reviewer found that this type of surgery can be equally performed by either an orthopedist or a podiatrist. There is no data demonstrating a difference in outcomes depending upon the type of specialist (orthopedic surgeon versus podiatrist) in performing the procedure. There is no reason why this patient cannot be safely and effectively treated by a podiatrist.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested skilled nursing facility (SNF) services, or in the alternative, admission to a rehabilitation facility for intensive physical and occupational therapy for treatment of his medical condition status post ischemic stroke. The physician reviewer found that the records document that this patient had lacunar stroke resulting in weakness, incoordination, and imbalance. The current medical literature reports a relatively small portion of patients who suffered from an acute first-ever stroke received rehabilitation consultation and inpatient rehabilitation treatment. In addition, studies show that post stroke rehabilitation at home can be effective in improving mobility and self-care. This patients initial care resulted in significant functional improvements. At that time, he was appropriate for discharge to home with assistance, or to a board and care facility. He did not require the ongoing daily nursing care that could be only provided at a SNF. Consistent with these findings, subsequent SNF services, or in the alternative, admission to a rehabilitation facility for intensive physical and occupational therapy were not and are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for individual mental health therapy sessions, twice a month. With regard to first-line therapies for moderate major depressive disorder, researchers report that data supports use of antidepressant monotherapy, psychotherapy, and the combination of both. With worsening anxiety and depression symptoms, increasing the frequency of this patients psychotherapy while continuing in medication management is consistent with these current treatment recommendations. The records provided for review document major depressive disorder and anxiety despite treatment with multiple therapeutic agents. Specifically, the patients symptoms did not substantially improve with fluoxetine, escitalopram, or trazodone. Given the support in the medical literature, individual mental health therapy sessions, twice a month, are 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested advanced lipoprotein testing for evaluation of the his dyslipidemia. Findings:  Three physician reviewers found that based on the records provided, this patient presents with a diagnosis of dyslipidemia. In this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phosholipase A2 (Lp-PLA2), sub-classifications of LDL, high density lipoprotein (HDL) cholesterol subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine. Treatment changes or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: Reviewer 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50-100 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 recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found, and Zepatier with ribavirin for 16 weeks when NS5A resistance is present. These guideline recommendations are based on clinical trial results showing a 58% cure rate with Zepatier for 12 weeks when NS5A resistance is present. However, the guidelines now state that lack of NS5A resistance testing should not be an impediment to treatment, and recommend 12 weeks of Zepatier when NS5A resistance testing is not available. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment is needed regardless of fibrosis stage, and the request for Zepatier 50-100 mg tablets for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 authorization and coverage for magnetic resonance imaging (MRI) of the left knee for evaluation of his left knee pain. Findings:  The physician reviewer found that the documentation submitted for review does not support a medical indication for MRI. Per AIM guidelines, MRI of the left knee is not indicated unless the patient has completed a four to six week trial of medical therapy, including physical therapy. Although the patient had been taking NSAIDS for five weeks at the time of the left knee MRI request, the medical records do not document a trial of supervised physical therapy for his knee pain. Also, there is no documentation of any findings on physical exam that raise concern for a ligament tear. The reviewers determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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

A 52-year-old female enrollee has requested for magnetic resonance imaging (MRI) scan of the hips and spine for evaluation of her medical condition. Findings:  The physician reviewer found that there is no clinical concern of spinal infection or metastatic disease. There is also no clinical concern of avascular necrosis of the hips. An MRI of the spine is medically indicated when there is clinical evidence of a disc herniation, spinal stenosis, spinal infection or metastatic disease. However, this patient does not have a clinical presentation to support MRI of the spine. An MRI of the hip is utilized to evaluate for suspected avascular necrosis. However, this patient does not have a clinical presentation to support MRI of the hips. In regards to the patients concern of osteoporosis, DEXA studies are one of the accepted imaging studies for the evaluation of osteoporosis. MRI studies are not utilized in the evaluation of bone density. This patient had a recent normal DEXA study, which was not suggestive of a diagnosis of osteoporosis. All told, there is insufficient medical evidence to support an MRI of the spine and hips for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 54-year-old female enrollee has requested real-time cardiac monitoring for an evaluation of her medical condition. Findings:  Three physician reviewers found that event recorders of the type invoked are much more likely than standard approaches to detect culprit arrhythmias, since the latter have a notoriously high rate of missing such events. It was therefore appropriate for the cardiologist to order this type of monitoring in this situation since the patients symptoms were of sufficient severity, on more than one occasion, to result in her hospitalization. This method is commonly used among the cardiology community and has been documented to be of significant clinical value.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old male enrollee has requested Provigil for the treatment of his fatigue and sleepiness. Findings:  The physician reviewer found that the treatment of side effects of medications is a common practice in medicine. Provigil has been used for conditions not yet approved by the FDA, including multiple sclerosis, cancer, depression and other conditions. Despite appropriate therapy for vitamin B12 deficiency, this patients peripheral neuropathy is severe enough to necessitate administration of opiates and Lyrica. These medications have controlled pain and enabled the patient to function adequately. This appears to be the best regimen for his condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested Nutropin AQ Nuspin for treatment of the enrollees growth hormone deficiency. Findings: The physician reviewer found that the review of the submitted documentation demonstrates the patient has extreme short stature, poor growth velocity, low growth factors, and a morphological abnormality of the pituitary gland that is known to be associated with GH deficiency. The patient has had an excellent response to GH therapy. GH therapy is medically necessary for treatment of GH deficiency until epiphyseal closure. In the setting of extreme short stature with morphological abnormality of the pituitary gland and unequivocally low IGF-1 level, provocative GH testing is not necessary to confirm the diagnosis. As such, the requested Nutropin AQ Nuspin 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 pediatrics with sub-specialty certification in pediatric endocrinology 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: A patient has requested authorization and coverage for fentanyl patch 100 mcg and oxymorphone HCL 40 mcg. The Health Plan has denied this request indicating that the requested medications are not medically necessary for treatment of the patients fibromyalgia. The submitted documentation does not support the medical necessity of the requested medications. The patient may have opioid-induced hyperalgesia. The patient has been treated with medications, physical therapy, transcutaneous electrical nerve stimulation, and acupuncture and still has considerable pain. This patient should be slowly detoxified as the patient is receiving opioids in the amount of 600 mg of morphine equivalents per day. In addition, the records do not indicate that there is a history of malignancy, recent urine toxicology results, or an opiate maintenance agreement in place. Therefore, fentanyl patch 100 mcg and oxymorphone HCL 40 mcg are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medications 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 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.