Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:A 70-year-old male enrollee has requested authorization and coverage for Ofev.Findings:  The physician reviewer found that the patient is noted to have idiopathic pulmonary fibrosis, chronic respiratory failure, and obstructive sleep apnea syndrome per the provider. This patient was on Esbriet for 10 months with no response. The provider recommended treatment with Ofev due to failure of Esbriet. The Health Plan denied coverage for Ofev. Per the Health Plan, the requested medication is investigational for treatment of this patient. The medical literature supports the superior efficacy of Ofev in this clinical setting. This patient has a high resolution computed tomography of chest taken in the previous year. This scan showed extensive bilateral interstitial thickening and bibasilar bronchiectasis, which is compatible with idiopathic pulmonary fibrosis (IPF) and not compatible with other conditions even in the presence of a few right pleural calcifications. Likewise, the age, sex, clinical picture, and the pulmonary function tests from several months previous are all compatible with IPF as well. Of note, this patients forced vital capacity is less than 50%, indicating this patient has severe disease. There is a lack of other specific treatment for this patients medical condition. He has failed treatment with Esbriet. In sum, the Ofev is likely to be more beneficial for treatment of this patients medical condition than other treatment options. Final Result: The reviewers  determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers are board certified in internal medicine with sub-specialty certification in pulmonary disease and are actively practicing. The reviewers are 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

The patient is a 51-year-old woman with a diagnosis of Crohns disease. She also suffers from arthritis, which is a non-intestinal manifestation of her Crohns disease. Celebrex has been prescribed to decrease the side effects attributed to the non-steroidal anti-inflammatory drugs (NSAIDs).  The patients request for authorization and coverage was denied by the Health Plan based upon a determination that Celebrex is not medically necessary.The use of Celebrex is medically indicated for this patient with Crohns disease. Multiple studies have shown that NSAIDs may potentially exacerbate the underlying irritable bowel disease in patients such as this one. As the patient is symptomatic from arthritis due to Crohns disease, a Cox II inhibitor is a reasonable choice to treat her arthritis symptoms. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco 10/325 mg 90 tablets (30-day-supply).The 2016 Centers for Disease Control and Prevention guidelines state, Nonpharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and non-opioid pharmacologic therapy, as appropriate. The April 2017 Federation of State Medical Boards guidelines recommended, Opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective and maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met. The American Society of Interventional Pain Physicians guidelines state that prescribing of opioids less than 40 morphine equivalents a day is consider low dose therapy. In this case, the patient has chronic low back and neck pain due to moderate to severe canal stenosis of the cervical and lumbar spine. She underwent laminectomy surgery with no improvement in her symptoms. Notes indicate that the patient has been actively involved in physical therapy. She has also tried epidural steroid injections, with limited duration of benefit. She is currently requesting continuation of chronic opioid therapy with Norco. Based on the records, the patient has not shown any aberrant or drug seeking behavior. There is no documentation of inconsistent urine drug screens. The medication is managing the patients pain and allowing for the performance of activities of daily living. The current medical evidence supports the requested medication quantity of 90 tablets per 30 days in this setting. Therefore, Norco 10/325 mg 90 tablets (30-day-supply) are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of this patient. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty 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: Experimental/Investigational
Decision: Upheld

A 53-year-old male enrollee has requested balloon sinuplasty for treatment of his chronic sinusitis.  Findings:  Two physician reviewers found that the patient has refractory frontal sinus disease.  The documentation noted persistent, slowly worsening, bilateral frontal sinus pain, pressure, and headaches.  Per the provider, the patients symptoms have been refractory to three prior sinonasal surgeries and medical management consisting of numerous antibiotics and sprays.  The provider noted that the ethmoid sinuses and maxillary sinuses were open and resected, but the frontal sinus showed some mucoid edema possibly consistent with acute inflammation.  In this patients case, the requested services are not likely to be superior over other available treatment alternatives.  Balloon sinuplasty is a relatively new technique that has been shown to have some benefits in frontal sinus opacification.  Some of the references do state that there may be some improvement with the use of this balloon assisted technology.  However, most of the references demonstrate a lack of randomization of patient symptomatology and indicate that some patients require hybrid techniques with the use of combined balloon sinus dilation and standard functional endoscopic surgical techniques to achieve adequate success.  At present, functional endoscopic sinus surgical techniques for the management of chronic rhinosinusitis refractory to medical management are still considered the surgical treatment of choice.In this patients case, the documents provided do not demonstrate any specific failure of medical management and do not show adequate physical examination of the change in the patients condition after a trial of medical therapy.  There is a lack of documentation regarding the type of medications utilized and response to these medications.  There was no accompanying radiographic report regarding the sinus CT scan.  Thus, the requested balloon sinuplasty (CPT codes 31296 and 31297) is not likely to be more effective than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Mavyret 100-40 mg tablets. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus, genotype 1a.According to the 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients be treated with Mavyret three tablets daily for eight 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. For these reasons, Mavyret 100-40 mg tablets to treat the patients hepatitis C is supported as medically necessary. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the Afirma Gene Expression Classifier test for evaluation of her medical condition.   Findings:  Three physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  The Afirma test utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  In sum, Afirma Gene Expression Classifier testing was likely to have been superior over other methods of evaluating this patient.   Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   All three reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and are 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: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Findings:  The physician reviewer found that as noted in the medical literature, one crucial element of success in treating eating disorders with complex and comorbid psychiatric issues is sustained coping strategies such as dialectical behavior therapy (DBT). Moreover, the patient must become able to refeed herself independently and have a strong support system to transition to a less restrictive level of care. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment (Klaehn, et al). Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the appropriate level of care. Applying the CALOCUS to this patients presentation, treatment at the RTC level of care is supported as medically necessary. The patient has a composite score of 23, which is consistent with non-secure 24-hour services with psychiatric care, such as RTC level of care services. Given this support, the RTC services provided were and are medically necessary for treatment of this patients behavioral health issues. 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 subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested medications Tafinlar 75 mg and Mekinist 2 mg for treatment of the enrollees metastatic adenocarcinoma of the cervix. Findings: Three physician reviewers found that Tafinlar in combination with Mekinist are approved for use in the treatment of metastatic melanoma who have a BRAF V600 mutation. There is very little information on the presence of BRAF mutations in cervical cancer and a lack of support for the use of these drugs in cervical cancer. These drugs are also not within National Comprehensive Cancer Network Guidelines for treatment of adenocarcinoma of the cervix. The study by Le Tourneau and colleagues indicated that choosing chemotherapeutic agents just by molecular assays is not better than conventional therapeutic decisions. Due to lack of clinical data in medical literature to support treatment of adenocarcinoma of the cervix with Tafinlar 75 mg and Mekinist 2 mg, the requested medications are not likely to offer clinical benefit when compared to conventional standard therapies.Final Result: Three 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: Overturned

A 21-year-old female enrollee has requested residential eating disorder for treatment of her eating disorder and depression.  Findings:  The physician reviewer found that the patient remains at high-risk in the absence of an effective course of intensive treatment prior to step-down transitioning to community-based programming. She has failed less restrictive treatment settings in this course of illness and her complex psychosocial stressors will more than likely produce enough distress to undermine treatment in a lower level of care at this time.  This patient requires the structure and 24-hour supervision afforded by residential placement to cement the therapeutic skills necessary for success, and premature discharge places the patient at risk for morbidity and acute hospitalization. Accordingly, residential treatment services were and are medically necessary for treatment of the patients medical conditions.
Appeal type: Medical Necessity
Decision: Upheld

A 67-year-old male enrollee has requested brand name Seroquel for treatment of his diagnosed major depressive disorder. Findings:  The physician reviewer found that testing ensures that generic products perform the same as the respective brand name products.  In general, there is a possibility that a generic medication may result in differences in clinical outcome.  However, in this case, the patients reports of clinical deterioration center on sleep, irritability, and pain.  Seroquel is not indicated for these symptoms.  Further, reasonable evidence-based alternatives to the brand name medication have not yet been exhausted.  Such interventions include increasing the dose of the generic quetiapine since the bioavailability may be less compared to the brand, and targeting the irritability by either increasing the relatively low-dose serotonergic enhancing medication or converting to a serotonin-norepinephrine reuptake inhibitor, as these medicines can treat mood, anxiety, and pain.  All told, the requested brand name Seroquel is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Quillivant XR 25 mg/5 mL. While literature supports methylphenidate as treatment for attention-deficit/hyperactivity disorder (ADHD) for young children, there are multiple formulations of this medication due to different requirements for each individual patient. Caballero and colleagues noted that with regard to the treatment of patients with ADHD, there are multiple formulations, including immediate release (administered two to three times/day), solid extended release (ER), or transdermal patch. The authors reported that methylphenidate extended-release oral suspension (MEROS) is a once daily, long-acting liquid preparation that has demonstrated favorable safety and efficacy in patients with ADHD. This young patient has reportedly failed an adequate trial of long-acting Ritalin due to not being able to swallow the capsule and experiencing adverse effects when the capsule was opened up and sprinkled on food. When treated with Quillivant XR, the patient was noted to have improved in compliance, reactivity, and control of ADHD symptoms. While the active drug, methylphenidate, is the same in capsule form and Quillivant XR, the delivery method is different as well as the absorption. Quillivant XR is appropriate for treatment of this patients ADHD given her inability to swallow pills and non-tolerance to capsule form of the methylphenidate when sprinkled on food. Moreover, the requested Quillivant XR 25 mg/5 mL is in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Given this support, the requested Quillivant XR 25 mg/5 mL 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 psychiatry with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 16-year-old female enrollee requested authorization and coverage of continued inpatient treatment for the treatment of bipolar disorder, mixed, moderate and oppositional defiant disorder.  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: An enrollee has requested authorization and coverage for Supartz injection series in the left knee.Findings: An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. 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 options are clearly limited. The patient has tried and failed other conservative treatments with the alternative being surgery. Thus, Supartz injections for the left knee are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services were 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.