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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lorazepam 1 mg, 90 tablets every 30 days. Findings:  The physician reviewer found that he records provided for review document that this patient has been treated with a high dose of benzodiazepine for anxiety for many years. The providers documented that the patient has not been amenable to guidance on tapering his lorazepam dose or augmentation strategies, which have been attempted over the last year. The patients current treatment plan should include weaning the dose of the lorazepam to the lowest tolerated, individual psychotherapy, and alternative psychopharmacologic options. There is a lack of evidence that the patient has undergone treatment with cognitive behavioral therapy, which has been demonstrated to be effective for patients with anxiety disorder. For these reasons, the requested lorazepam 1 mg, 90 tablets every 30 days is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication dosage 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Saxenda 18 mg pen injector.Obesity is associated with increased risk of multiple comorbidities. Few medications are currently available for the treatment of obesity, and their effectiveness and benefits often fade when the drugs are discontinued. Saxenda (liraglutide) may be prescribed for chronic weight management as an adjunct to a reduced-calorie diet and increased physical activity. Nuffer and Trujillo noted, Data demonstrated that liraglutide can successfully achieve weight-loss benchmarks of 5% or more and 10% or more loss from baseline. In this case, the patient has struggled to lose weight despite a strict diet and regular exercise. Saxenda may assist this patient with losing weight and may have a positive effect in terms of her comorbidities related to her obesity, such as obstructive sleep apnea. Thus, the requested Saxenda 18 mg pen injector is medically necessary for the treatment of the patients 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 internal medicine with subspecialty certification in endocrinology, diabetes and metabolism 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 parent of a nine-year-old female enrollee has requested  Saizen for treatment of the enrollees precocious puberty.  Findings:  The physician reviewer found that gonadotropin-releasing hormone agonists have been suggested to slow growth, a decrease which may be overcome through the use of growth hormone therapy. Growth hormone therapy in such cases will accelerate growth, which may augment final adult height. In this case, the patients bone age could advance further with respect to chronologic age, which would shorten her adult height. The literature to date is lacking in consensus with respect to this topic. The current medical literature does not support the medical necessity of the requested medication in this patients case, as the use of Saizen remains of unproven efficacy in this clinical situation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco for treatment of his neck and chronic low back pain.  Findings: The physician reviewer found that based on the documentation submitted for review, Norco has not been established as medically necessary for treatment of the patients medical condition. In this case, the patients providers have advised against continued Norco use due to negative opiate drug screens that are inconsistent with his Norco prescription. In this clinical setting, the providers recommendation for treatment with pain management and physical therapy are medically reasonable and appropriate for treatment of the patients neck, shoulder and back pain. As such, Norco is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for Endoscopic Retrograde Cholangiopancreatography (ERCP). The submitted documentation does not support the medical necessity of the requested services. The patient was appropriately treated for the finding of pancreatic duct stone with extracorporeal shockwave lithotripsy (ESWL). Repeat endoscopic retrograde cholangiopancreatography (ERCP) may not be of benefit in the long term beyond ESWL alone. There was no finding of a pancreatic duct stricture requiring endoscopic therapy. Ee-intervention is not always required for recurrent stones. Additionally, because ERCP is associated with risks, including pancreatitis, less invasive modalities such as endoscopic ultrasound can be used to identify stones rather than ERCP. ERCP can be reserved to intervene if known stones are present. In this case, it is not clear that stones are present in the pancreatic duct, and stones were not found on recent ERCPs. In addition, the ERCP is associated with procedural risks. Under these circumstances, ERCP is not is medically necessary to treat the patients medical condition at this time.Final Result: The reviewer determined that the requested services 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 internal medicine, with subspecialty 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: Upheld

The parent of a four-year-old female enrollee has requested sensory integration therapy for treatment of the enrollees sensory processing dysfunction.  Findings:  Three physician reviewers found that sensory integration therapy has been proposed for many years. To date, there is no scientific basis to support its use. It is not a medical therapy, but a psycho-educational one and is considered experimental. There is no evidence to support such therapy as beneficial for this patient. It is highly likely the patient will benefit from some therapy and from assistance from her family and teachers; however, there is no basis for sensory integration therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the Intracept procedure (intraosseous ablation of the basivertebral nerve). The records document that this patient has a history of chronic low back pain that has persisted for several years. Treatment has included medications, physical therapy, and injection therapy without sustained benefit. The patients provider has recommended treatment with the Intracept procedure. Fischgrund and colleagues demonstrated that Intracept procedure is superior to continued conventional treatment with physical methods and injections for the treatment of patients with chronic back pain. Truumees and colleagues noted that the ideal candidate for the Intracept procedure has axial low back pain with Modic endplate changes on magnetic resonance imaging (MRI). In this case, the patient has ongoing low back pain with significant MRI changes. The peer-reviewed medical literature suggests that the Intracept procedure is superior to continued conservative care with data suggesting benefit beyond two years. Given this support, the requested Intracept procedure (intraosseous ablation of the basivertebral nerve) is 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 Intracept procedure (intraosseous ablation of the basivertebral nerve). Final Result: The reviewers determined that the requested services are 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 reviewer 1 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C.  Findings:  Two physician reviewers found that in this patients case, there is a lack of documentation of advanced hepatic fibrosis.  This has import relative to prioritizing medically necessary treatment on the basis of nationally-recognized American Association for the Study of Liver Diseases and Infectious Diseases Society of America treatment guidelines.  The guidelines noted that immediate treatment is assigned the highest priority for those patients with advanced fibrosis (Metavir F3), those with compensated cirrhosis (Metavir F4), liver transplant recipients, and patients with severe extrahepatic hepatitis C. Based on available resources, immediate treatment should be prioritized as necessary so that patients at high risk for liver-related complications and severe extrahepatic hepatitis C complications are given high priority.  In this patients case, he does not meet classification per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines as highest priority, high priority, or even at increased risk for medically necessary treatment.  All told, the requested medication Harvoni for 12 weeks is not medically indicated for the treatment of this patient. Final Result: Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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

A 53-year-old female enrollee requested Aubagio for medical treatment of her multiple sclerosis.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication for the treatment of this patient.  The medical records note a diagnosis of relapsing-remitting multiple sclerosis.  The patient has been on Rebif, but has developed intolerable side effects of pain and bruising.  Per the submitted records, she is unable to self-inject due to incoordination and needle phobia.  The inability to self-inject is an appropriate reason to switch to an oral disease modifying agent.  All told, Aubagio is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old male enrollee has requested Provigil 200 mg, 90 tablets per month for the treatment of his obstructive sleep apnea (OSA). Findings:  The physician reviewer found that this patient had an AHI of 6.1 indicating mild OSA that would typically not require management with CPAP and an elevated Epworth Sleepiness Score. Provigil was prescribed, and his dosage was increased to 300 mg daily. The increase to 600 mg daily is not clinically indicated for mild OSA or explained in the record provided. Furthermore, this dosage is more than the maximum FDA approved dose of 400 mg daily. The packet insert notes that increasing the daily dose of Provigil above 400 mg does not increase efficacy.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested L5-S1 anterior lumbar interbody fusion (single level) for treatment of her back pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The current medical evidence does not support the requested services in this clinical setting.  There is no evidence of spinal instability at L5-S1.  The American Pain Society has developed evidence-based recommendations on the use of interventional diagnostic tests and therapies, surgeries, and interdisciplinary rehabilitation for low back pain of any duration, with or without leg pain.  Chou and colleagues noted that in this setting, patients should be considered for intensive interdisciplinary rehabilitation with a cognitive/behavioral emphasis.  For individuals with persistent back pain despite non-interdisciplinary therapies, the authors recommended counseling these patients regarding interdisciplinary rehabilitation.  Per the submitted documentation, this patient has not had such therapy.  All told, the requested L5-S1 anterior lumbar interbody fusion (single level) is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 37-year-old female enrollee requested authorization and coverage of gastric bypass surgery for the treatment of morbid obesity.  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: Medical Necessity
Decision: Overturned

A 26-year-old female with relapsing-remitting multiple sclerosis (MS) is requesting authorization for Tysabri for the treatment of her condition. Reviewer findings:The reviewing physician found the data in regard to Tysabri shows this therapy is substantially more effective than the current disease-modifying therapies.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a 15-year-old female enrollee has requested authorization and coverage for implantation of a patient-activated cardiac event recorder for evaluation of the enrollees palpitations. Findings:  The physician reviewer found that There is sufficient support for the requested services in this clinical setting. In the study by Giada and colleagues involving patients with symptoms of palpitations and without severe structural heart disease, a diagnosis was significantly more likely with the use of an implantable loop monitor than with a conventional strategy. This patient has had recurrent palpitations for several years which has eluded a definitive diagnosis. This is despite empirical therapy with a beta blocker. Based on the available data and given the inability to arrive at a diagnosis after both conventional ambulatory monitoring and electrophysiological study, the requested implantation of a patient-activated cardiac event recorder is likely to be superior over other methods of evaluating this patient. Final Result: Two of three reviewers determined that the requested services are 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for residential treatment center (RTC) level of care services. The enrollee has a history of depression and suicidal ideation. The enrollee entered a residential treatment center, with diagnoses of major depressive disorder, single episode, severe; cannabis use disorder, severe; alcohol use disorder, severe; oppositional defiant disorder, and inhalant use disorder; severe.  Upon admission, the enrollee endorsed passive suicidal ideation without plan or intent. The six dimensions of CALOCUS include risk of harm, functional status, comorbidity, recovery environment, resiliency and treatment history, and acceptance and engagement. For risk of harm, the enrollees score is 3, due to no active suicidal or homicidal ideation exists, but extreme distress and/or a history of suicidal/homicidal behavior is present. For functional status, the enrollees score is 3, due to recent gains and/or stabilization in functioning have been achieved while participating in treatment in a structured, protected, and/or enriched service. For comorbidity, the enrollees score is 3, due to recent substance use that has a significant impact on the presenting condition has been arrested, due to the use of a highly structured or protected setting or through other external means. For recovery environment level of stress, the enrollees score is 4, due to the threat of severe disruption in life circumstances, including the threat of imminent incarceration of either the caregiver or self, the lack of a permanent residence, or the immersion in an alien and hostile culture. For recovery environment level of support, the enrollees score is 2, due to family/primary caretakers are willing and able to participate in treatment if requested to do so, and have the capacity to effect needed changes. For resiliency and treatment history, the enrollees score is 4, due to previous treatment has not achieved complete remission of symptoms or optimal control of symptoms; even with intensive and/or repeated exposure to treatment. For treatment acceptance and engagement, the enrollees score is 3, due to an ambivalent, avoidant, or distrustful relationship with clinicians and other care providers. The enrollees composite CALOCUS score is 22, which correlates with Level 4, an intensive integrated service level of care without 24-hour psychiatric monitoring.Final Result: The reviewer determined that the requested service were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old male enrollee has requested artificial disc replacement surgery for the treatment of his headaches and neck pain. Findings:  Three physician reviewers found that cervical artificial disc replacement remains experimental for the treatment of cervical spondylosis. More outcomes data is needed in the mid-term and long-term to establish the safety and efficacy of this device. Complications in the mid-term and long-term are not clear at this time. Additionally, this patient also had previous fusion at other levels of the cervical spine. Outcomes of artificial disc surgery in cases of previous cervical fusion are not known, and complications are not known.