Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Rezum procedure. Findings:  Two of the three physician reviewers found that as there is increasing evidence of benign prostatic hyperplasia obstructed outflow and increasing post-void residual, it is appropriate to address this trend that is not improving on medical therapy. There is sufficient support for the minimally invasive Rezum procedure in this clinical setting. Three-year data show non-inferiority to transurethral resection of the prostate, with less risk of worsening impotence, retrograde ejaculation, and incontinence. Therefore, the requested Rezum procedure is likely to be superior over other treatment options. 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 reviewers 1, 2 and 3 are board certified in urology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50/100 mg tablets for 16 weeks for treatment of the enrollees hepatitis C. 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 recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with Zepatier with ribavirin for 16 weeks when NS5A resistance is present. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment is needed regardless of fibrosis stage, and Zepatier 50/100 mg tablets for 16 weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee requested Consentyx for treatment of his psoriasis. Findings:  The physician reviewer found that psoriasis is a chronic skin disease with new emerging understanding of the contributing immunologic pathways. Consequently, new targeted therapies have been developed to gain better control over this disease. This patient has failed therapy. He is requesting coverage for Cosentyx. The letter of appeal indicates a contraindication to methotrexate, cyclosporine and acitretin. However, there is a lack of laboratory data provided to demonstrate a contraindication to methotrexate, such as a transaminitis or evidence of active hepatitis infection. Further, there is no confirmation of treatment failure or adverse reaction to these treatments. Since the patient has not demonstrated a failure to respond or related adverse effects from an oral systemic agent for treatment of psoriasis, the requested Consentyx is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested passive chiropractic manipulation and/or physical therapy modalities/procedures for treatment of his neck muscle strain. The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. According to Walker and colleagues there is currently no evidence that supports or refutes these interventions, provided clinically meaningful difference for pain or disability in people with low back pain when compared to other interventions.  Additionally, Eriksen and colleagues report that no prospective study has examined the incidence of adverse reactions following spinal adjustments using upper cervical techniques and the impact of this care on clinical outcomes. According to the documentation submitted for review, there is a lack of documentation of objective functional deficits to support the medical necessity for therapy. Based on the medical literature cited above and the documentation submitted for review, the request for passive chiropractic manipulation and/or physical therapy modalities/procedures is not medically necessary for treatment of the patients medical condition.  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 physical medicine and rehabilitation 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: Experimental/Investigational
Decision: Upheld

A 45-year-old female enrollee requested authorization and coverage of gastric bypass utilizing the duodenal switch technique. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three  physician reviewers concluded that the requested surgery is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an in-home sleep study for evaluation of her medical condition.  Findings:  The physician reviewer found that the in-home sleep study was medically necessary for evaluation of the patients medical condition. In this case, the patient presented with complaints and physiological indicators suggestive of obstructive sleep apnea. The presence of snoring and gasping and choking are well known symptoms of obstructive sleep apnea (Myers, et al). In addition, her complaints of morning headaches and non-restorative sleep are symptoms associated with obstructive sleep apnea (Jordan, et al). Furthermore the patients report of a crowded upper airway is another risk factor for sleep disordered breathing (Ito, et al). Given the presence of the multiple risk factors for obstructive sleep apnea, the in-home sleep study to rule in or out a sleep related breathing disorder is within current practice guidelines (Epstein et al 2009).  All told, the services were medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in sleep 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for weekly individual therapy (psychotherapy) sessions. Findings:  The physician reviewer found that the records provided for review indicate that this patients symptoms do not reflect the triad of PTSD of hyperarousal, withdrawal, and hardened re-experiencing. Overall, she does not have a constellation of depressive symptoms suggestive of the need for ongoing individual therapy. There is no documented significant impairment of routine functioning. Moreover, the patient is not manifesting as a danger to herself or others, self-injurious behavior, or acute mental health symptoms such as psychosis, mania, severe depression or severe anxiety, uncontrolled eating disorder behavior, volatility, or major degradation of interpersonal relationships. Given these findings, the requested services are not medically necessary for treatment of this patients medical condition.  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 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 Sovaldi for treatment of his hepatitis C.  Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions.  According to the guidelines, patients with hepatitis C, genotype 2 infection should be treated with daily Sovaldi and weight-based ribavirin for 12 weeks.  Sovaldi is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 2 regardless of fibrosis stage.  For these reasons, the requested treatment with Sovaldi is medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested coverage for magnetic resonance imaging (MRI) of the knee. At issue in this case is whether MRI of the knee is medically necessary for the treatment of the patients medical condition. Findings:  The physician reviewer found that MRI is the optimal modality to evaluate internal derangement in the knee. Plain x-rays are of limited value because the menisci and ligaments are not visible on plain x-rays. X-rays can show findings such as a mass or a congenital abnormality. A MRI alone has little to offer for patients with non-traumatic knee pain, no mechanical symptoms, and findings of degenerative arthritis on x-ray. The incidence of abnormal findings such as meniscal tears is high in asymptomatic patients. Therefore, MRI findings must be carefully correlated with clinical signs and symptoms. Obtaining a MRI without correlation with a detailed clinical examination can lead to unnecessary conclusions and unnecessary surgery. The medical evidence does not support the requested service in this clinical setting. Therefore, the requested MRI of the knee is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a bone density test.Findings:  Two out of three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. Serial central dual-energy x-ray absorptiometry (DEXA) testing is an important component of osteoporosis management. The International Society for Clinical Densitometry (ISCD) guidelines indicate that intervals between bone mineral density testing should be determined according to each patients clinical status. This patient had a DEXA, which showed osteopenia. It was important to monitor progression of bone density with a follow-up bone density test. Therefore, the bone density test performed was likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were likely to have been 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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intravenous (IV) antibiotics. Studies note that many infections can be managed with oral antibiotics, which avoid the adverse effects of intravenous administration. In this case, while the patient references planned gum surgery, the current medical literature does not support the use of IV antibiotics to prevent the spread of an oral infection or for the treatment of periodontal disease. Given that the documentation does not reflect evidence of bacterial infection, the requested medication is not medically indicated. Therefore, IV antibiotics are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in infectious 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyperthermic intraperitoneal chemotherapy (HIPEC) surgery. This patient presented with metastatic disease at the time of initial diagnosis. The patient is noted to have poor prognostic features including a likely appendiceal origin and signet ring histopathology. The patients records indicate that he experienced at least partial response to the standard regimen of FOLFOX. The patients provider has recommended treatment with cytoreductive surgery and HIPEC. The use of HIPEC for appendiceal adenocarcinoma is supported by small studies that have shown a survival advantage in this particular clinical situation (Shaib, et al.). The National Comprehensive Cancer Network (NCCN) guidelines acknowledged that, patients with peritoneal carcinomatosis of appendiceal origin, [is] a group that has seen greater benefit with the cytoreductive surgery/HIPEC approach. Furthermore, the guidelines state that, complete cytoreductive surgery and/or intraperitoneal chemotherapy can be considered in experienced centers for selected patients with limited peritoneal metastases. This patient is being treated in a comprehensive cancer center with experience in HIPEC and is undergoing the proper evaluation for cytoreductive surgery with the inclusion of HIPEC. Given these findings, the requested HIPEC surgery 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 HIPEC surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.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 internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in medical oncology 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

A 62-year-old male has requested coverage for a motorized scooter for treatment of his hemiplegia affecting dominant side.  Findings:  The physician reviewer found that the documentation provided for review does not support the medical necessity of a POV (power scooter). The determination of medical necessity for a POV is based on the following criteria: 1) The patient is unable to ambulate independently with use of an assistive device; 2) The patient does not have sufficient upper extremity function to propel a manual wheelchair; 3) The patient has demonstrated the ability and willingness to safely operate a power-operated vehicle (POV); 4) A POV is needed to perform in-home MRADLs; 5) The patients residence will accommodate such a device. These criteria are generally used to support the medical necessity of a POV (Dicianno and Tovey). In the case under review, records indicate that the patient is capable of self-propelling a lightweight manual wheelchair in order to perform his MRADLs. Therefore, a power scooter does not meet generally accepted criteria for medical necessity for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female has requested a stress test (stress echocardiogram) for evaluation of her intermittent chest pressure.  Findings:  The physician reviewer found that based on the records provided the patient presents with no cardiac risk, very atypical (likely non-anginal) chest discomfort, a normal cardiovascular physical exam and a normal electrocardiogram. In this clinical circumstance, the pretest likelihood of significant obstructive coronary disease is low, such that additional cardiac evaluation with stress testing is not supported as medically necessary. If stress testing were thought to be indicated, then routine exercise electrocardiography should be sufficient given the patients low pretest risk, normal baseline electrocardiogram, and ability to ambulate on a treadmill. Current guidelines endorsed by several national organizations also do not consider exercise stress echocardiography appropriate in this setting (Douglas, et al). Adding imaging to conventional exercise electrocardiography in low risk patients with low risk Duke treadmill scores has not been show to be of incremental benefit (Poornima, et al).
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for duodenal switch procedure with hiatal hernia repair.Findings:  The physician reviewer found that the request for the duodenal switch procedure is not medically necessary at this time. The completion and documentation of a thorough multidisciplinary evaluation is required. Both a psychological and dietary evaluation is clinically indicated. The patient underwent a psychological evaluation, however a dietary evaluation specifically in regards to the duodenal switch procedure and review of fat and water soluble micronutrient intake deficiency is not documented. Although the patient attended an in-Plan nutrition class, it is not documented that the effects of the duodenal switch procedure were discussed. While the patients surgeon indicates he has counseled the patient regarding the potential nutritional deficiencies associated with the duodenal switch procedure, there is a lack of sufficient objective documentation demonstrating the patients understanding of the nutritional needs unique to duodenal switch such as a dietary evaluation by trained, licensed registered dietician as recommended by published standard primary and re-operative guidelines. In regards to the request for hiatal hernia, it is generally recommended that a hiatal hernia be repaired when performing bariatric surgery, as it is considered part of the overall bariatric procedure. As such, repair of hiatal hernia alone without duodenal switch is not medically necessary. If a dietary evaluation documenting patient understanding of the dietary restrictions associated with the duodenal switch procedure as well as anticipated patient compliance is obtained, the requested procedure would be considered medically necessary. For the reasons provided, the request for duodenal switch procedure with hiatal hernia repair is not medically necessary for treatment of the patients medical condition at this time. Final Result: The reviewer determined that the requested procedure is not medically necessary for treatment of the patients medical condition at this time. Therefore, the Health Plans denial should be upheld at this time.  Credentials/Qualifications: The reviewer is board certified in 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.