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

A 20-year-old male enrollee has requested Opana ER for treatment of his chronic pain secondary to rheumatoid arthritis and failed back surgery syndrome.  Findings:  The physician reviewer found that review of the medical literature reveals multiple publications discussing the use of opioids for non-terminal pain. A paper published in the Southern Medical Journal in 2007 addresses this particular topic. Many authors have reported (in case reports and case series) prolonged and satisfactory analgesia for up to six years using moderate opioids (up to 195mg of morphine or equivalent). It is also important to note that different opioids have different effects on patients, that is, analgesia may be achieved with some opioids but not with others. This response varies from patient to patient and may require trying different molecules before analgesia is achieved.In the case of this patient, his provider documented on the said date that the patient tried methadone, transdermal fentanyl and oxycodone without adequate pain relief and thus confirmed failure of three of the alternative medications recommended by the Health Plan. Given the patients chronic pain, pain level and failure to respond to other agents, Opana ER is medically appropriate and necessary to control his pain.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medications, Carisoprodol 350mg tablet, and Zolpidem 10mg tablet dosed at two (2) tablets at bedtime. The enrollee has a history of chronic hip pain and chronic insomnia. The enrollee has additional diagnoses of major depressive disorder, single episode, and anxiety disorder. Records show the enrollee currently takes Cymbalta, 30 milligrams, and Remeron, 15 milligrams. The enrollee also takes Xanax for anxiety; 2 milligram tablets twice a day as needed. The physician documented physical symptoms of dizziness/vertigo, muscle weakness, tremors in the enrollees hands and muscle spasms. The progress note indicates the enrollee has a risk of substance abuse relapse. The physician ordered Ambien, 20 milligrams, at bedtime, until the enrollees hip pain has significantly reduced. After an urgent care visit, the treating provider requested soma for the enrollee, noting the enrollee had tried and failed baclofen and Flexeril. No specifics or documentation of the failure was reported in the records. Zolpidem is intended to be used for the short-term management of insomnia. The standard adult dosage is adults, five or 10 milligrams (men) or 5 milligrams (women) immediate-release or 6.25 or 12.5 milligrams (men) or 6.25 milligrams (women) extended-release immediately before bedtime. Maximum daily dose is 10 milligrams immediate-release and 12.5 milligrams extended-release. The dosage of 20 mg per day exceeds the maximum daily recommended dose. Also, the concurrent use of zolpidem and sedatives or hypnotics may result in an increase in central nervous system depressant effects.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in (insert specialty) 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Rectiv. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition.The submitted documentation supports the medical necessity of the medication at issue. The use of Rectiv as first-line therapy for anal fissure is supported by guidelines from the American College of Gastroenterology. Rectiv has proven effective in placebo-controlled trials. Treatment of anal fissure with Rectiv is in accordance with generally accepted standards of medical practice and clinically appropriate for this patients condition. The patient has had improvement with this medication. For these reasons, Rectiv is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty 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

This patient is a 58-year-old female who has a history of Stage IIA infiltrating ductal and lobular carcinoma of the left breast. She is status post lumpectomy; sentinel lymph node biopsy showed metastasis in a lymph node (0.2cm). She had an incidental (less than 1 cm) bronchoalveolar lung cancer removed following the breast cancer diagnosis. The patient is estrogen receptor and progesterone receptor positive and human epidermal growth factor receptor 2 negative. Adjuvant chemo/hormonal therapy is clearly indicated. The patients chemotherapy protocol has included dose dense adriamycin/cytoxan followed by dose dense Taxol or Taxotere followed by radiation therapy and hormonal therapy. Neulasta was prescribed for chemo-related neutropenia.  Due to changes in the patients health plan, Neulasta was later denied, and Neupogen authorized.  The patient would like to continue with the Neulasta at two-week intervals versus eight injections per chemotherapy cycle with Neupogen. The dose dense adriamycin/cytoxan followed by dose dense Taxol protocols as originally described by the CALGB protocol employs Neulasta to allow deliverance of the chemotherapy at two-week intervals. This has produced superior results as compared to the same regimen given without Neulasta every three weeks. The use of Neulasta with this adjuvant chemotherapy regimen is the community standard of care and should be authorized. Based upon the information set forth above, 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lupron injections. Lethaby and colleagues note that gonadotropin-hormone releasing analogues (GnRHa), such as Lupron, induce a state of hypo-oestrogenism that shrinks uterine fibroids, but have unacceptable side effects if used long-term.  Potential adverse effects in premenopausal women include cardiovascular effects due to androgen deprivation and decreased bone density. For this reason, GnRHa therapy is primarily used as transitional therapy to bridge patients from late perimenopause to menopause as in this case. While the submitted documentation noted FSH levels that were not in the postmenopausal range, the patient was reported to be postmenopausal. Given that heavy bleeding and fibroids resolve postmenopause, the requested services are not medically indicated. Therefore, Lupron injections are 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 obstetrics and gynecology 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 34-year-old female enrollee has requested adult mental health partial treatment eating disorder services for the treatment of her eating disorder. Findings:  The physician reviewer found that the submitted clinical evidence indicates that the patient has had a long-standing eating disorder with associated anxiety and depression. The patient was appropriate for partial hospital/day treatment level of care at the time of her admission to the program. However, on the basis of the treatment records, she had made clear and apparent improvement. The physician notes indicate stable weight, no overt eating disorder behavior, no clear indication of a significantly disordered mood, thinking or behavior, and no particular medical problems. Although the patient indicates that she was experiencing anxiety, the latter was not a prominent issue in the physician notes. There was no reason to expect that the patient would regress if discharged. Any relatively minor laboratory abnormalities could be followed on an outpatient basis. It would have been medically prudent and appropriate to treat the patient at a lesser level of care. Therefore, the services provided were not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient is requesting reimbursement for the left L4-5 epidural steroid injection with fluoroscopy. The patient has a history of chronic low back pain, with an injury in his late teens, followed by several low back injuries with sciatica over the years. The record indicates treatment with physical therapy (PT), chiropractic care, medications and epidurals with fair relief. He had an exacerbation of his chronic low back pain treated conservatively. He underwent magnetic resonance imaging (MRI) of the lumbar (L) spine revealing multilevel degenerative changes most pronounced at the L4-L5 level producing severe left and moderate right foraminal stenosis with moderate left foraminal stenosis at L5-sacral (S) 1 level. The provider recommended an epidural steroid injection to the low back. The patient underwent an interlaminar steroid epidural injection at the L4-L5 level on the left and follow-up two weeks later reported that he was better after the injection. He underwent an additional steroid epidural injection at the L4-L5 level with follow-up two weeks later reporting about relief from the injection.Final Result: The reviewer determined that the requested service was medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in anesthesiology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for general anesthesia received with a colonoscopy and endoscopy.The patient was undergoing a routine colonoscopy and endoscopy. The patient did not have any heart, lung, kidney or liver disease. There was no documentation of a history of alcohol or substance abuse. There was no detailed description of previous history of difficulties with anesthesia or sedation with past procedures documented. The treating providers note that monitored anesthesia care was needed due to difficulty of sedation failed to provide a specific explanation or concern. The treating providers letters and medical records do not identify or provide any details regarding the patients reported difficulty of sedation. In addition, the anesthesiologists record does not include an ASA classification or difficult airway score, so there is no evidence of medical necessity based on these grounds. Under these circumstances, the general anesthesia received with a colonoscopy and endoscopy was not medically necessary for the patient.Final Result: The reviewer determined that the services at issue were not medically necessary for the patient. Therefore, the Health Plans denial should be upheld.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: Medical Necessity
Decision: Upheld

A 58-year-old male enrollee has requested Lyrica for the treatment of his spinal stenosis. Findings:  The physician reviewer found that there are no published studies supporting the use of Lyrica in spinal stenosis. While there is a clinical trial underway (NCT 00638443) at the University of Rochester to evaluate Lyrica in patients with spinal stenosis, to date there is inadequate evidence demonstrating that Lyrica is effective for this condition. Based on the lack of peer-reviewed data establishing the safety and efficacy of Lyrica in this clinical setting, the necessity of the drug has not been established.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested bilateral orbital decompression with bone and fat removal, performed in one surgery for treatment of her Graves ophthalmopathy. Findings:  The physician reviewer found that orbital decompression surgery can be performed bilaterally in a simultaneous procedure. However, there is a paucity of medical literature demonstrating an improved health outcome with the simultaneous performance of the surgical corrections. Specifically, the clinical data do not suggest the risk of blindness is decreased with bilateral surgery, the healing time is faster, or that there is less blood loss with simultaneous surgery. The complications are the essentially the same in both scenarios, and may be worse if bilateral vision loss were to occur in an elective procedure such as this. Importantly, there is nothing in this patients medical records suggesting that the requested surgery is urgent as there is no evidence of either compressive optic neuropathy or severe exposure keratopathy. For these reasons, the In-Plan providers should provide the care the patient needs in the staged approach as planned. Although the patient may appreciate the convenience of a single procedure, the risks do not justify the convenience, and in fact may cause further morbidity.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni for eight 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 and the Infectious Diseases Society of America, 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, and advanced fibrosis is not required for treatment.  Per the guidelines, treatment-naive, genotype 1 patients should be treated with Harvoni.  Patients with viral loads less than 6,000,000 IU/mL can be treated for eight weeks.  These guideline recommendations are based on multiple randomized clinical trials.  The current guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication regimen 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: Overturned

The enrollee is requesting authorization and coverage for acupuncture service. The enrollee has menopausal symptoms; including hot flashes, night sweats and mood swings. The enrollee is trying to avoid hormone replacement therapy. The enrollees physician explained that all non-hormonal medical management options have been exhausted except gabapentin.  The enrollee is not interested in gabapentin because of daytime sleepiness and dizziness. She is interested in acupuncture because she wants to rule out all possible treatment options prior to considering hormone replacement therapy. Scientific literature and studies have shown the efficacy of acupuncture for menopausal symptoms. Studies report a standardized six-week acupuncture treatment produced a fast and clinically relevant reduction in moderate-to-severe menopausal symptoms. Literature shows acupuncture significantly reduced the occurrence of hot flushes and sudden sweating, along with improving other symptoms, such as sleep disorders, tightness in the chest, irritability, and bone pain. Studies also demonstrated acupuncture reduced the number of hot flashes and other vasomotor symptoms and improved quality of life for menopausal women. The clinical benefits persisted for at least six months.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is a board certified acupuncturist 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Viekira XR, one tablet twice daily for a duration of 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 and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. This applies regardless of fibrosis. Per the guidelines, treatment naive genotype 1b patients should be treated with Viekira XR for 12 weeks. This recommendation is based on multiple high-quality clinical trials showing cure rates of over 90% and safety. The medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  The guidelines also cite data showing increased survival with earlier treatment. For these reasons, Viekira XR, one tablet twice daily for a duration of 12 weeks is 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

The patient is a 62-year-old male who had a rise in his PSA of 6 in 2002 to 10.7 in 2004. He had a total of five needle cores biopsied. On examination, his prostate was described as small and free of any nodules. He has had 3D conformal radiation therapy recommended but he would like to proceed with intensity modulated radiation therapy (IMRT).Based upon the information provided it appears the patient has a Gleason score of 6 in minute quantity of the right lobe of the prostate with a PSA of 10.7 and a tumor stage of T1c. The patient has a low volume of tumor. Based upon Partins Tables there is a 62% chance of cancer being limited to the prostate, a 33% chance of capsular penetration, a 4% chance of seminal vesicle involvement, and a 2% chance of pelvic lymph node involvement. Furthermore, based upon the patients relatively high PSA and low volume of tumor there is potential the tumor is outside of the prostate. As such the patient may require treatment of the pelvis as well as the prostate.Given this patients condition, 3D conformal radiation therapy is the appropriate radiation therapy for this patient. There is no evidence IMRT would be superior for this patient. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee requested authorization and coverage of the medication Vioxx for the treatment of osteoarthritis.  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 medication is 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 Mavyret for eight 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1a patients should be treated with Mavyret 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 infection, regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. All told, Mavyret for eight weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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.