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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for losartan brand name Cozaar manufactured by Teva instead of losartan brand name Cozaar manufactured by Solco Healthcare. When the U.S. Food and Drug Administration (FDA) approves a generic drug product, it has met rigorous standards established by the FDA with respect to identity, strength, quality, purity and potency. Generic drugs are required to have the same active ingredient, strength, dosage form and route of administration as the brand name product.  Through review of bioequivalence data, the FDA ensures that the generic product performs the same as its respective brand name product. This standard applies to all generic drugs, whether immediate or controlled release. In this case, there is not sufficient documentation that the patient has had a significant adverse reaction to the generic drug losartan, made by Solco Healthcare. The efficacy of both the brand name and generic drug made by either manufacturer are equivalent. Therefore, the requested losartan brand name Cozaar manufactured by Teva instead of losartan brand name Cozaar manufactured by Solco Healthcare is 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 internal 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: Overturned

A 59-year-old male enrollee has requested alprostadil (Edex) 40mg, two times per week injections for treatment of his erectile dysfunction. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  Intracavernosal injections such as Edex are indicated for men who cannot tolerate or fail treatment with phosphodiesterase type 5 (PDE-5) inhibitors such as Viagra, Levitra, and Cialis.  Contraindications to Edex include conditions predisposing the patient to priapism, anatomic deformation of penis, and known hypersensitivity to alprostadil or other prostaglandins.  In this patients case, the records do not indicate a contraindication to Edex.  The patient reported that Edex has been effective.  All told, alprostadil (Edex) 40mg, two times per week injections are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an Orthovisc injection series in both knees. 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. 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, there is a history of lasting benefit from prior viscosupplementation. Furthermore, the documentation indicates other conservative measures including physical therapy and cortisone injections have been tried, with limited success. The medical evidence supports the requested services in this clinical setting. Therefore, the requested Orthovisc injection series in both knees  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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a 35-year-old female who is more than two-years post-operative from a gastric bypass for morbid obesity. She is seeking authorization for panniculectomy, abdominoplasty, and brachioplasty for excess skin secondary to an almost 200 pound weight loss. The Health Plan has denied authorization because there is a lack of documentation supporting the medical necessity of the procedures.The records provided include poor quality photocopies of photographs of the patient and a progress note and surgical authorization request from the board certified plastic surgeon.  The submitted information provides no objective evidence of medical necessity for the proposed procedures. Although some cases involving this much weight loss do necessitate skin reduction procedures, the records and photocopies provided in this case do not demonstrate that the proposed panniculectomy, abdominoplasty, and brachioplasty are medically warranted. Therefore, I have determined the requested procedures are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested for a Lap-band procedure for treatment of her obesity. Findings:  The physician reviewer found that patients with a BMI between 35 and 40 must have significant co-morbidities in order to be considered appropriate candidates for weight loss surgery. This patient has a BMI of 37. Serious weight related co-morbid conditions such as hypertension or diabetes are not documented. Sleep apnea is listed by the patient as one of her conditions, but is not mentioned in the medical evaluation or surgical evaluation. Furthermore, there is no evidence of a sleep study documenting obstructive sleep apnea. In the absence of evidence of significant weigh-related co-morbidities, this patient does not meet medical necessity criteria for weight loss surgery.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old male enrollee has requested psychiatric residential treatment for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that in this patients case, the submitted documentation supports the medical necessity of a portion of the services at issue.  This patient had failed treatment in the outpatient setting, and his impaired executive functionality, characterological organization, psychiatric symptomatologies and prominent polysubstance use contributed to a sustained pathological change in baseline.  The records note continued risk taking behaviors that would have posed risk of serious harm to the patient, and possibly others, outside of a 24-hour structured setting.  Thus, psychiatric residential treatment  services were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a male enrollee requested the Vest Airway Clearance System for medical treatment of hiss congenital myotonic dystrophy and asthma.  Findings:  The physician reviewer found that in this case, the patient presents with congenital myotonic muscular dystrophy, asthma and autism. Although the majority of studies of HFCWO systems have involved patients with cystic fibrosis, these systems were developed for any patient with poor airway clearance and the inability to perform other clearance maneuvers. Aggressive pulmonary care is essential for this population of patients because of the risk of morbidity from respiratory complications. Therefore, based on the medical literature cited above and the documentation submitted for review, the requested Vest Airway Clearance System is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old female enrollee has requested physical therapy and occupational therapy for treatment of her status post cerebral hemorrhage. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested therapy. Acute stroke care includes cerebral reperfusion interventions when appropriate, addressing hemodynamic issues, secondary stroke prophylaxis, various supportive management strategies and preventing complications such as aspiration and deep venous thromboses (Adams, et al). Functional impairments due to acquired brain insults such as stroke can improve with time, such as natural recovery processes (Turner-Stokes, et a), but are also amenable to rehabilitation interventions. In this case, the patient sustained an acute stroke with significant functional impairments.  She has been undergoing inpatient rehabilitation, and has made significant progress. The physical and occupational therapy notes submitted for review demonstrates that she has plateaued with respect to her function. She is ambulating about 80 feet at moderate assistance. She continues to require contact guard to minimum assistance for dressing and moderate assistance for toileting. Based on the documentation submitted for review, further physical therapy and occupational therapy services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old female enrollee has requested the medication Humira 40mg/0.8ml (quantity four) for treatment of her medical condition. Findings:  The physician reviewer found that the medical records submitted with this case do not document the patients diagnosis or the medication treatment plan. Although the requested higher dosage of Humira may be appropriate based upon clinical reasoning, the records supplied do not explicitly document the medical reasoning as to why the higher dosage of Humira has been requested or is medically necessary. Humira is a therapy that has potentially life-threatening toxicity and must be used under the direction of a physician for both on-label and off-label use. In the absence of clear documentation as to the patients medical condition and the necessity of the increase in Humira dosage frequency, the patients appeal should be denied.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old male enrollee has requested an occipital nerve stimulator for treatment of his occipital neuralgia. Findings:  Three physician reviewers found that with review of the all of the documentation provided including the additional records provided by the patient does not demonstrate that occipital nerve stimulation is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is still a lack of evidence that the patient has tried and failed anticonvulsant or antidepressant therapy. These medications are cited in peer-reviewed literature as safe and efficacious therapy in occipital neuralgia. There is a lack of scientific literature establishing occipital nerve stimulation as a superior modality compared to these standard treatment options. Therefore, the contention that the patient is likely to derive greater benefit from occipital nerve stimulation than from standard modalities remains unsupported.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old female enrollee has requested genetic testing (BRAF and KRAS mutation analysis) for evaluation of her metastatic gallbladder adenocarcinoma. Findings:  Two physician reviewers found that the testing at issue was not likely to be more effective for this patient than other available treatment options. According to Sosman and colleagues, approximately 50% of melanomas harbor activating (V600) mutations resulting in BRAF. Vemurafenib, the oral BRAF inhibitor may produce tumor regressions in melanoma patients with BRAF. However, this patient presents with carcinoma of the gallbladder with peritoneal metastases, and there is a lack of support in the medical literature for BRAF and KRAS mutation analysis performed in this clinical setting. Moreover, mutational analysis at this time is not considered the standard of care in the management of carcinoma of the gallbladder. As such, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intravenous immunoglobulin (IVIG) treatment. Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  This patient has been diagnosed with CIDP.  CIDP is autoimmune inflammatory neuropathy that is well-known to respond to IVIG.  In this patients case, it is medically appropriate to administer IVIG on intermittent basis to keep the disease process under control.  The current medical evidence supports the requested services in this clinical setting.  All told, the requested IVIG treatment is medically indicated for the treatment of this patient. Final Result: The reviewer patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Xifaxan 550 mg for treatment of the enrollees small intestinal bacterial overgrowth. Findings: The physician reviewer found that the records indicate that this patient has IBS-D and small intestinal bacterial overgrowth. Xifaxan has been proven to be highly effective in small intestinal bacterial overgrowth and in IBS-D for eradication of bacteria and symptom relief (Scarpellini, et al; Pimentel, et al). For bacterial overgrowth, eradication was demonstrated in 80% versus 54% for placebo (Scarpellini, et al). In addition, Xifaxan had greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole and levofloxacin (Pimentel, et al; Lauritano, et al). Moreover, the U.S. Food and Drug Administration (FDA) has approved Xifaxan for the treatment of IBS-D, and the medication has been demonstrated to be safe and effective in randomized placebo-controlled trials for IBS-D (Pimentel, et al; Schoenfeld, et al). The formulary alternatives required for IBS-D treatment would not address the patients small intestinal bacterial overgrowth, and the formulary alternatives required for bacterial overgrowth treatment would not address IBS-D. For these reasons, the use of Xifaxan 550 mg three times daily for 14 days is supported as medically necessary for the treatment of this patients IBS-D.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

A 44-year-old female enrollee has requested breast reduction surgery for treatment of her macromastia.  Findings:  The physician reviewer found that this patient has signs and symptoms documented that are consistent with symptomatic macromastia that would likely benefit from breast reduction surgery. This appears to be consistent with the treating surgeons analysis as well. However, given her previous bariatric surgery and significant weight loss, the surgeon has recommended that the patient reach her goal weight prior to the reduction. This recommendation is consistent with the paper recently published by Losken which states that, Overweight (body mass index, 25 to 30) or moderately obese (body mass index, 30 to 35) patients are at increased risk of general and wound-healing complications, and efforts are made for further weight loss before the procedure. Nevertheless, the issue of weight loss prior to breast reduction is not fully settled as can be seen in the study by Zubowski and colleagues. The authors concluded that, Although this study has shown that patients who are average body weight have fewer complications than obese patients after breast reduction surgery, it has not shown an increasing incidence of complication with increasing degrees of obesity. A stable weight appears to be of greater clinical significance than an individuals absolute weight. Therefore, the patients request for breast reduction surgery should be reconsidered once the patient achieves a stable weight.
Appeal type: Experimental/Investigational
Decision: Overturned

A 58-year-old female enrollee requested  positron emission tomography (PET) imaging with computed tomography (CT) attenuation from skull to thigh for medical evaluation of her T-cell lymphoma. Findings:  Two physician reviewers found that the Centers for Medicare and Medicaid Services (CMS) has approved the use of PET/CT in the evaluation, staging, treatment progress and follow-up for all solid tumors including lymphoma. Thus, the use of PET/CT in this instance is likely to be more beneficial for this patient than any regular imaging modality.
Appeal type: Medical Necessity
Decision: Overturned

A 37-year-old male enrollee has requested physical therapy for the treatment of his post traumatic vertigo and dizziness. Findings:  The physician reviewer found that the submitted evidence demonstrates that the patient presents with persistent dizziness following a mild traumatic brain injury. His symptoms are precipitated by change in position. Physical therapy involving vestibular rehabilitation has been shown to be an effective therapy for a variety of central and peripheral balance disorders (see Black, et al. and Girardi, et al.). The absence of diagnostic findings on vestibular testing does not rule out the presence of impairment. In fact, the patients history is consistent with post-concussive syndrome with dizziness. As the study by Gurr and colleagues demonstrates, vestibular rehabilitation has been shown to be an effective treatment in brain injury patients. Therefore, vestibular rehabilitation is medically appropriate and necessary for this patients clinical situation.
Appeal type: Medical Necessity
Decision: Overturned

A 23-year-old female enrollee requested authorization and coverage of gastric bypass surgery.  The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz tablets.Findings: According to the most recent published Alopecia Areata Consensus of Experts (ACE) guidelines, treatment of alopecia totalis/universalis includes systemic steroids, methotrexate, cyclosporine, and contact sensitization with diphenylcyclopropenone (DPCP) or squaric acid. Few treatment methods have been evaluated by randomized controlled trials to determine the most efficacious modalities to treat alopecia areata. Therefore, it is challenging for clinicians to guide patients regarding the best therapeutic options. According to the ACE, there was consensus on the effectiveness of monotherapy with oral corticosteroids, cyclosporine, and Janus kinase (JAK) inhibition therapy. In this case, the patient has seen improvement with Xeljanz. There is support for the requested medication in this clinical setting. Therefore, Xeljanz tablets are medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology 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 10-year-old female enrollee has requested  for growth hormone therapy (Genotropin) for treatment of the enrollees growth hormone deficiency secondary to a non-functioning pituitary adenoma. Findings:  The physician reviewer found that this patients history is significant for chronic asthma and numerous allergies to foods, dust, pollens, molds and medication. The patient has no contraindication to Genotropin based on the information provided.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested abdominoplasty and incisional hernia surgery for treatment of her medical condition.  Findings: The physician reviewer found that the request for abdominoplasty is medically necessary for treatment of the patients medical condition. Based on the medical documentation provided, she has a significantly abnormal condition of the upper and lower abdomen as well as  a severe bulge of the upper abdomen consistent with a large incisional hernia and a significantly overlapping lower abdominal pannus.  There is support in the medical literature for performing the procedures concurrently. The patient has indications for both procedures as the abdominoplasty approach can provide adequate exposure for the repair of the large incisional hernia and to allow for resolution of her abdominal excess. Thus, an abdominoplasty approach in this patient satisfies medical necessity as a combined procedure with concurrent treatment of her hernia. All told, the incisional hernia surgery performed at the same time as the requested abdominoplasty is medically necessary for treatment of the patients medical condition.  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 physician reviewer is board certified in plastic 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.