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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for acupuncture services for treatment of the enrollee who has a history of migraine headache. Findings:  The physician reviewer found that the submitted medical records as well as the medical literature do not demonstrate the medical necessity for the services at issue. While a study of acupuncture therapy for management of migraines was promising, there was considerable potential for bias since the study was non-blinded and the patients were allowed to self select treatments. Additionally, in this patients case, the reviewed medical records reflect the patient has a 20-year history of migraine headache that are not addressed as related to any spinal impairments or following a specific trauma to the head, spine or upper extremities. The progress report from a provider outlined the patients migraine management along with management of stress in the neck and shoulders. However, there were no submitted clinical record that this patients migraine onset, for the dates of services in question, were related to the patients prior medical history of migraine management. As such, the reviewed medical records do not identify a medical condition that would support acupuncture management. Final Result: The reviewer determined that the services at issue were 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 oriental 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested non-emergent transportation services to and from appointments for treatment of the enrollee, who has been diagnosed with neovascular age-related macular degeneration.  Findings: The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  This patient requires frequent injections.  The patients vision is not clear enough, especially after the injections, to drive herself home after the appointments, or to take public transportation alone.  If she does not have someone to give her a ride or accompany her on public transportation, non-emergent transportation is the only viable option for this patient.  Thus, the requested services are needed to allow the patient to receive necessary medical treatment.  All told, the requested non-emergent transportation services to and from appointments with the Health Plans ophthalmology department are medically indicated 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: Physician reviewer is board certified in ophthalmology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. Tomosynthesis is a valuable tool in evaluating areas of asymmetry. The ability to discern whether an area of asymmetry represents an occult mass as opposed to summation of overlapping tissue is often clarified with these cross-sectional images. As such, breast tomosynthesis was likely to be more beneficial for evaluation of the patients breast tissue than any available standard therapy. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of your medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   All three reviewers are board certified in diagnostic radiology 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 58-year-old male enrollee has requested for an open prostatectomy for treatment of his prostate cancer. Findings:  The physician reviewer found that the requested procedure is standard of care in this setting as set forth in the Management of Localized Cancer guide, which is based on recommendations from the Prostate Cancer Clinical Guideline Panel of the American Urological Association. It is appropriate for the patient to proceed with open radical prostatectomy at this time.
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 virus.  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. This applies regardless of fibrosis stage or viral load. Per guidelines, patients with liver transplant are considered high priority for treatment. Viekira Pak is not recommended by AASLD guidelines after liver transplant. The guidelines recommend Harvoni monotherapy (for 24 weeks) only in treatment-naive ribavirin-ineligible patients with genotype 1. The only AASLD recommendation for ribavirin-eligible genotype 1 liver transplant patients is Harvoni with weight-based ribavirin for 12 weeks. This is based on the SOLAR-1 trial of Harvoni in post-transplant recipients, which demonstrated 96% sustained virologic response in this population, and a low rate of discontinuation due to ribavirin side effects (Charlton, et al). In this case, the patient does not have anemia or sufficient renal failure that would preclude ribavirin use. In addition, the medical records do not mention the addition of ribavirin to the Harvoni regimen. Per AASLD/IDSA guidelines, the requested treatment with Harvoni for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection. 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 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Xeljanz 5 mg. Barton and colleagues report that topical corticosteroids are the preferred first-line treatment for pediatric patients with alopecia areata, as they hold the highest level of evidence, followed by contact immunotherapy. The authors further report that more clinical trials and comparative studies are needed to further guide management of pediatric patients with alopecia areata and to promote the potential use of novel therapies, including Janus kinase (JAK) inhibitors. Jabbari and colleagues note that open-label studies of ruxolitinib and tofacitinib (brand name Xeljanz) showed dramatic clinical responses in patients with moderate-to-severe alopecia areata. King and colleagues reported that treatment JAK inhibitors for 24 weeks in patients with alopecia areata was efficacious and generally well tolerated. In this clinical setting, given that the patient has failed first-line therapy with steroids and contact sensitizers, the requested medication is medically indicated. Therefore, Xeljanz 5 mg 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 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: Upheld

A 58-year-old female enrollee has requested alendronate, 70 mg tablet for treatment of her history of osteoporosis.  Findings:  The physician reviewer found that the patient in this case was diagnosed with osteoporosis based on an x-ray of left knee that was read as consistent with mild osteoporosis. An x-ray can make the diagnosis of osteoporosis with the finding and assessment of fractures according to the National Osteoporosis Foundation. The patients x-rays of lumbar spine from the date in question indicated a limbus defect vs avulsion fracture anterosuperior L4 and disco-vertebral height of L3-L4 is slightly reduced. With these findings, this patient should have a follow-up imaging study, such as a magnetic resonance imaging (MRI) of lumbar spine, to determine whether this is a fracture. This recommendation is consistent with the International Society for Bone Densitometry, which considers an equivocal bone fracture to be sufficient indication for additional imaging. In this patient, the DEXA scan showed normal average bone density, with normal T-scores of hip and spine, -0.2 and 0.1 respectively. The T-score of the right femoral neck was 0.4, which is also normal. These normal average scores, however, could be masking low scores in any individual vertebra, so a full DEXA report would be helpful in establishing this patients diagnosis. Fosamax can have potentially serious side effects. Therefore, a diagnosis of osteoporosis must be confirmed in order for its use to be clinically justified. Had additional clinical and radiological information been provided in this case in support of the diagnosis of osteoporosis, showing that the findings in the patients spine are indeed due to fracture, and that any individual vertebral body has a T score below -2.5, then the diagnosis of osteoporosis could be sustained. However, in the absence of this information, the requested Fosamax therapy has not been demonstrated to be medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee has requested dermolipectomy/panniculectomy for the treatment of her rash under the folds of her abdominal skin. Findings:  The physician reviewer found that the Health Plans criteria for dermolipectomy/panniculectomy is consistent with generally accepted medical necessity criteria in this setting. Panniculectomy is medically appropriate for patients who have undergone substantial weight loss resulting in overhanging or redundant skin and fat, have maintained that weight for longer than six months, have a panniculus that hangs to or below the level of the pubis, and there is photographic evidence of a chronic or recurring condition refractory to appropriate medical therapy for a period of at least six months. In this case, the patient has documented weight loss of greater than 100 lbs., her weight has remained stable for more than six months and her panniculus hangs to or below the level of the pubis. However, the provided photographs do not show any condition of the sub-pannus skin to reflect the patients reported skin irritation. More importantly, there is no documentation by the physicians of any medically supervised treatment of rash or skin irritation for at least six months. Each physician has documented the patients complaints, yet no physician has documented any prescription of medication, powder, ointment or other skin treatment. Furthermore, a physician description that the patient has some signs of irritation and moisture is not detailed enough to provide a clear picture of the underlying condition. Thus, the proposed procedure is not medically necessary under general concepts of medical necessity.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for Ampyra 10 mg ER for treatment of the enrollees relapsing-remitting multiple sclerosis. Findings:  The physician reviewer found that The submitted documentation supports the medical necessity of the requested medication. Ampyra is U.S. Food and Drug Administration (FDA) approved to improve walking speed. Additionally, there are other data demonstrating improvement of measures of quality of life function in patients with multiple sclerosis with this drug.  In this patients case, the medical evidence supports the requested medication over the Health Plans alternatives. Baclofen is used for spasticity or stiffness in the legs associated with multiple sclerosis. It does not aid in improving walking speed, fatigue or other measures of daily living function, which is what Ampyra does. Dexamethasone is a potent steroid used for a few days in multiple sclerosis patients experiencing an attack. It calms down an attack acutely, but is not a long-term treatment. Rebif is a thrice weekly injection used to reduce the likelihood of an attack, but this medication does not change functional daily living capacity. Therefore, Ampyra is unique in its action by improving neurologic function in daily living. In sum, Ampyra 10 mg ER 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 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: Upheld

A 32-year-old female enrollee has requested a continuous passive motion (CPM) machine for the treatment of her condition. Findings:  The physician reviewer found that there is no peer-reviewed class 1 literature to support the efficacy of the CPM machine for autologous chondrocyte transfer procedures. There is no data to show improved outcomes in the mid-term and long-term with the use of the CPM machine after this type of knee surgery. The requested equipment is considered to be experimental in this case. Standard postoperative management in the form of rehabilitation and physiotherapy without the CPM machine is medically appropriate 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 genetic testing (Mitochondrial Full Genome Analysis MT-TL1 m.3243A>G). Findings: The reviewer found that the submitted documentation supports that the requested genetic testing is medically necessary. This patient has a family history of MELAS (mitochondrial encephalopathy lactic acidosis and stroke-like episodes) due to m.3243A>G mutation in the mtDNA. This is present with varying degrees of heteroplasmy in her daughter and grandchildren, who have varying degrees of symptoms. As mtDNA is maternally inherited, it can be presumed that this patient has some degree of mtDNA mutation herself. While blood heteroplasmy levels are not fully indicative of levels throughout other organs, they can be suggestive and are easiest to obtain. This patient does have some symptoms consistent with milder forms of MELAS, including type II diabetes, migraines, exercise intolerance, and memory concerns, though these are common and can have complex causes. In this case, however, use of certain medications is not recommended in those with MELAS due to risk, and determining this patient's heteroplasmy levels can help define her risk of additional complications. The requested mtDNA sequencing for a single variant is a genetic test that will provide much benefit for this patient. Under these circumstances, the requested genetic testing is medically necessary for 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 reviewer is board certified in medical genetics and genomics, with primary specialty certification in clinical biochemical genetics, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the bilateral digital breast tomosynthesis screening mammogram performed for evaluation of the enrollees breast cancer screening. Findings:  2/3 of the physician reviewers found that there is sufficient support in the peer-reviewed literature for the procedure at issue in this clinical setting. According to the study by colleagues, the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. In addition, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. All told, the breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: 2/3 of the reviewers determined that the diagnostic procedure at issue was 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 diagnostic radiology 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 diagnostic radiology 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 diagnostic radiology 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:   An enrollee has requested carvedilol for treatment of her congestive heart failure. The physician reviewer found that based on the records provided, the patient has hypertension as well as reference to congestive heart failure. In this clinical setting, treatment with beta-blockers is indicated. However, hypertensive guidelines endorsed by several national organizations do not support a compelling medically necessary indication for the use of carvedilol over other beta-blocker medications. In addition, studies evaluating the use of beta-blockers in patients with congestive heart failure have demonstrated improved outcomes compared to several medications including bisoprolol, metoprolol and carvedilol. Therefore, the requested carvedilol is not supported as medically necessary for treatment of this patients hypertension.  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 cardiology 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 30-year-old female enrollee requested authorization and coverage of an increase in the  medication Zomig for the treatment of headaches.  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 increase in medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old female enrollee requested authorization and coverage of continued care with a non-contracted oncologist.  The enrollee had endometrial adenocarcinoma (uterine cancer) and is three years post-operative.  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 services are medically necessary for treatment of the patients medical condition.