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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nucynta 50 mg four times a day. Studies reported that Nucynta monotherapy was as effective as combination therapy with Nucynta and pregabalin in patients with severe, chronic low back pain with a neuropathic component. A review of Nucynta analyzed five years of data concerning the use of Nucynta for chronic pain and concluded that, head-to-head studies with World Health Organization (WHO) III opioids such as oxycodone controlled release and oxycodone/naloxone PR showed at least comparable pain relief in the treatment of moderate-to-severe musculoskeletal pain. Moreover, the authors noted that, rotation from poorly tolerated WHO III opioids to Nucynta provided effective pain relief and better symptom control for musculoskeletal pain compared to previous medication. In this case, the patient has chronic back and leg pain due to previous back surgeries. She has a diagnosis of lumbar post laminectomy syndrome. She has tried several different opioid pain medications and has allergies to morphine, Dilaudid, and Fentanyl. Most recently, she had tried Tylenol #4 and buprenorphine with gastrointestinal side effects. The patient reported using Nucynta in the past with much less gastrointestinal distress. Evidence from the recent reviews show that Nucynta does possess an improved gastrointestinal side effect profile. The studies also show that it has similar efficacy as traditional opioid medications such as oxycodone with the additional benefit of improved control of neuropathic pain. The records show that the patient has been compliant with her providers treatment plan, which has included epidural steroid injections. Furthermore, the provider noted that Nucynta has allowed the patient to function at work. For these reasons, the requested Nucynta 50 mg four times a day 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 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.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female enrollee requested authorization and coverage of vertical abdominal lipectomy, pubic reduction, and diastasis recti repair for the treatment of excess skin.  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 overturned the health plans denial on the basis that the requested surgery is  medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for the Acessa procedure, laparoscopy and surgical ablation of uterine fibroids with an out-of-network provider. The health plan denied this request as experimental/investigational. A review of the records indicates this enrollee has uterine fibroids. Her medical history includes a significantly irregular menstrual cycle due to perimenopause and a benign endometrial biopsy. A magnetic resonance imaging (MRI) revealed she has a uterine fibroid measuring 11 centimeters (cm) by 9.8 cm by 8.9 cm that occupies the majority of her uterus. Of note, her entire uterus measured 13 cm by 11 cm by 11 cm. The enrollee was treated with the medication, ulipristal, for an unspecified duration of time. It improved her overall pain, but it caused mood side effects. The enrollee had a consultation with interventional radiology, and she was not interested in proceeding with a uterine artery embolization (UAE). Although the Acessa system is approved for treatment of uterine fibroids, it is not evident this would be an appropriate treatment modality for this enrollee. Studies are limited to use of the system in patients with fibroids measuring up to 10 cm. The size of the dominant fibroid of 11cm in this enrollees uterus falls outside of the studied size range, as noted in her most recent MRI. More clinical studies are needed to support the safe and effective treatment of this procedure in patients with a large fibroid burden.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in Obstetrics and Gynecology 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Taltz. There is a lack of documentation regarding the extent of this patients psoriasis in terms of body surface area (BSA) involvement or prior disease severity to support an indication for treatment with Taltz. The medical records state that the patients psoriasis is well controlled while on Taltz. However, biologic medications including Taltz are not recommended for mild disease in the absence of extenuating factors such as difficult to treat areas. The U.S. Food and Drug Administration (FDA) has approved Taltz for the treatment of patients with moderate-to-severe plaque psoriasis, as defined by a BSA greater than 3%, or a psoriasis area and severity index (PASI) greater than 10 (Menter, et al.; Gordon, et al.). Similarly, the peer-reviewed medical literature recommends treatment with Taltz for patients with moderate-to-severe plaque psoriasis, which is not reported in the records provided for review. All told, the requested Taltz is not medically necessary for 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 dermatology with subspecialty certification in dermatopathology 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 LINX procedure for treatment of the enrollees gastroesophageal reflux (GERD).  Findings: Two physician reviewers found that appropriate patient selection is crucial before anti-reflux procedures. In prelude to surgical intervention for GERD, it is critical to document the presence of abnormal distal esophageal acid exposure, especially when anti-reflux surgery is considered, and reflux-related symptoms should be severe enough to outweigh the potential side effects of fundoplication. Each testing modality has a specific role in the diagnosis and work-up of GERD, and no single test alone can provide the entire clinical picture (Jobe, et al). This patient has undergone some of the required evaluation. Although this patient has GERD as predicated on her development of Barretts esophagus, it appears she has benefited at least 75% from acid suppression treatment, and as such cannot be considered medically refractory to acid-blocker drugs. Also, implantation of LINX in this patients clinical setting must be approached with caution since the device is not U.S. Food and Drug Administration (FDA) approved for use in patients with documented Barretts esophagus. All told, the requested LINX procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested procedure is 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 gastroenterology 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: Urgent Care
Decision: Upheld

A 45-year-old female enrollee has requested ambulance transportation for the treatment of her medical condition. Findings:  The physician reviewer found that the issue is whether the patients condition met the prudent laypersons definition of an emergency medical condition. Emergency medical condition is defined as a medical condition with symptoms of sufficient severity such that the absence of immediate treatment would result in placing the patients health in serious jeopardy, serious impairment of bodily functions and/or serious dysfunction of any bodily organ or part.  In this case, the patients condition does not meet the definition of emergency medical condition. The patient had experienced these symptoms on several occasions previously. When the ambulance arrived to pick her up, the emergency medical services team described her as ambulatory and in no distress. Her vital signs were normal. There was no complaint of chest pain. She did not require cardiac monitoring or medical intervention en route to the hospital. The patient could have been safely transported to the hospital by other means, such as a private vehicle. She had experience with this constellation of symptoms. A prudent layperson with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize her health.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested continued coverage for skilled nursing facility services at a post-acute care center for treatment of the enrollees medical condition.  Findings: The physician reviewer found that functional impairments due to acquired brain insults such as stroke can improve with time, but are also amenable to rehabilitation interventions.  The role of inpatient rehabilitative care for persons with significant functional deficits following stroke is relatively well-established in the medical literature.  In this patients case, he had major initial functional deficits following his most recent stroke.  He has been undergoing rehabilitative care at the skilled nursing facility level of care and has made modest progress.  However, his prognosis for functional recovery that will make a significant difference in his assistance needs in the near term is poor, in large part due to his persistent residual dense hemiplegia.  He is anticipated to require significant levels of assistance for most aspects of his care, including his self-care and transfers.  While ongoing rehabilitative services are appropriate and indicated, these services can be provided in a community setting, with custodial level services for his basic self-care.  There are no documented ongoing medical or skilled nursing needs requiring ongoing inpatient care in the submitted records. Therefore, skilled nursing facility services at a post-acute care center forward were not and are not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were not and 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 physical medicine and rehabilitation 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 parent of a 13-year-old female enrollee has requested reimbursement for residential treatment center (RTC) services for approximately four weeks for treatment of the enrollees anorexia nervosa, restricting type. Findings:  The physician reviewer found that the American Psychiatric Association (APA) treatment parameters for patients with eating disorders support the residential treatment center level of care services provided to this patient over four weeks as medically necessary. According to APA guidelines, orthostatic hypotension indicates a need for immediate medical hospitalization. The APA notes that orthostatic hypotension may be demonstrated by an increase in pulse of 20 BPM or a drop in blood pressure of 20 mm Hg standing. One week after admittance, this patient was reported to have a supine blood pressure of 99/65, supine pulse of 83, sitting blood pressure of 112/75, and sitting pulse of 89. Her upright blood pressure was 118/97 and upright pulse was 108.  Thus, she had an increased pulse of 25 beats per minute (BPM) when standing, fulfilling the APA criteria for 24-hour care. Additionally, the APA guidelines state that treatment for children and adolescents must be treated differently from adults. The APA cautions that, To avert potentially irreversible effects on physical growth and development, many children and adolescents require inpatient medical treatment, even when weight loss, although rapid, has not been as severe as that suggesting a need for hospitalization in adult patients. Since this patient was 13-years-old at the time of admission, and had an eating disorder for at least one year, she was at a vulnerable stage, necessitating extra care in her treatment. The APA further indicates that Patients need to both gain healthy body weight and learn to maintain that weight prior to discharge. This patient is documented as repeatedly stating that she does not have an eating disorder and intended to eat less once discharged. All told, the residential treatment center services provided on the dates in question were medically necessary for management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested authorization and coverage for Oxycontin 80 mg for treatment of the enrollees stated medical conditions of Lupus and fibromyalgia.  Findings:  The physician reviewer found that based on the records provided for review, authorization for Oxycontin 80mg is not medically necessary for management of this patients medical condition. Such narcotics and at the doses prescribed to the patient is presently indicated for severe cancer pain in patients who are opioid tolerant and with a limited life expectancy. This patient has been diagnosed with Lupus and fibromyalgia, both of which are non-malignant pain. Current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy and at that point controlled release narcotics if indicated with close monitoring by a certified pain management physician is recommended (Fishman).  Baron and McDonald reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. It would be in the patients best interest to wean off all opiates and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address her chronic pain.  In addition, high dose opiates may also cause adverse outcomes. Ballantyne and Mao reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. Any opioids as requested by the patient for her chronic pain would be contradictory to providing safe and effective healthcare. Overall, the medical records do not support the medical necessity of the requested medication. Specifically, the records should demonstrate a diagnosis of chronic malignant pain, diagnostic testing to confirm the diagnosis, as well as treatments tried and the patients response. All told, the requested Oxycontin is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sclerotherapy (CPT 36471). According to the Society for Vascular Surgery (SVS) and the American Venous Forum (AVF) have developed clinical practice guidelines the records provided for review do not support an indication for left SSV treatment. There is a lack of documentation of the location of the symptomatic residual varicosity in the thigh. The patient underwent GSV and SSV radiofrequency ablation and foam sclerotherapy in January 2020. There is no documentation in the medical records of functionally limiting symptoms or ulceration in the distal left lower extremity in the distribution of the distal SSV. Further, the patients symptoms may still improve following the recent procedures. All told, the requested sclerotherapy (CPT 36471) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested sclerotherapy (CPT 36471) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services are 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: Physician reviewers 1, 2, and 3 are board certified in surgery with subspecialty certification in vascular surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 33-year-old female enrollee has requested a total abdominal hysterectomy, partial bilateral salpingo-oophorectomy, unilateral salpingo-oophorectomy for treatment of her pelvic pain. Findings:  The physician reviewer found that the requested surgery is not indicated absent further evaluation and attempts at more conservative treatment.  As noted by the American College of Obstetrics and Gynecology, there can be many causes of pelvic pain. The American College of Obstetrics and Gynecology notes that a detailed history and focused physical examination are the basis for the differential diagnosis of chronic pelvic pain and should be used to determine appropriate diagnostic studies. Specifically, the history and physical examination should seek to identify the location, severity, quality and timing of the pain. the patient's record lacks sufficient details regarding her pain, including location, frequency, degree, exacerbating conditions, previous treatments tried, and details to determine if the etiology of the pain is from her uterus/ovaries versus her urinary or gastrointestinal systems.  In addition, the record has discrepancies between the review of systems and the conclusions. It also seems to be that her complaints of pain improved with Motrin., this patient has insufficient indications for a hysterectomy.  A total abdominal hysterectomy, partial bilateral salpingo-oophorectomy, unilateral salpingo-oophorectomy is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old female enrollee requested genetic testing for cystic fibrosis for evaluation of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services in this patients case.  Aquagenic wrinkling of the palms is a relatively recently identified condition.  This condition is relatively rare.   Recently, there has been association with the deltaF508 CFTR mutation, which is present in approximately 70% of northern European Caucasian cystic fibrosis patients.  It has been postulated that this may be the only manifestation of the carrier state of this genetic abnormality.  The current medical evidence supports the requested genetic testing in this clinical setting.  All told, genetic testing for cystic fibrosis is medically indicated that the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 34-year-old female enrollee requested authorization and coverage of genetic counseling and genetic testing. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees history of spontaneous abortion.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer partially overturned the Health Plans denial on the basis that the requested genetic counseling is medically necessary, but that the requested genetic testing is not medically necessary.