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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Viekira Pak 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 and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions.  Per the guidelines, treatment-naive, genotype 1a patients should be treated with Viekira Pak and ribavirin for 12 weeks.  The guidelines do not state that six months of testing is required to establish chronicity of hepatitis C prior to treatment, and state that acute hepatitis C is characterized by low or fluctuating viral load, which is not seen in this case.  This medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for surgery to fuse his back bones (lumbar spinal fusion) for treatment of his low back pain.  Findings: The physician reviewer found that evidence-based medical guidelines support lumbar spine fusion as an option for patients with ongoing symptoms, corroborating physical findings and imaging, and after failure of nonoperative treatment, for specific conditions including isthmic or degenerative spondylolisthesis with instability, and/or symptomatic radiculopathy, and/or symptomatic spinal stenosis. Objectively demonstrable segmental instability includes excessive motion as in isthmic or degenerative spondylolisthesis. Spinal instability criteria include lumbar intersegmental translational movement of more than 4.5 mm. This patient presents with constant severe low back pain, increased with motion and activity. Functional difficulty is noted in activities of daily living. His clinical signs and symptoms are consistent with imaging evidence of spondylosis with bilateral L5 pars defects resulting in unstable spondylolisthesis. There is radiographic evidence of spondylolisthesis with spinal segmental instability on flexion and extension x-rays with translation movement of 5 mm. A diagnostic pars defect injection test provided 100% relief of symptoms. The medical evidence supports the requested services in this clinical setting.  All told, the requested surgery to fuse his back bones (lumbar spinal fusion) and five days hospital stay are 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: Experimental/Investigational
Decision: Upheld

A 39-year-old female enrollee requested a wireless capsule endoscopy for medical evaluation of her abdominal pain, swelling, constipation, gas, and nausea.  Findings:  Three physician reviewers found that this patient presents with multiple GI complaints that have been extensively evaluated by multiple procedures including EGD, colonoscopy, wireless capsule endoscopy, and MRI, all of which were unremarkable. Based on the available peer-reviewed medical literature, wireless capsule endoscopy is not appropriate in this clinical setting due to negative endoscopies and the previously performed wireless capsule endoscopy. All told, the requested wireless capsuled endoscopy is not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a deep brain stimulator. Findings:  The physician reviewer found that in the medical literature, a study reported that deep brain stimulation (DBS) is a viable therapeutic option for the treatment of chronic neuropathic pain. Another study concluded that DBS demonstrated efficacy at 1 year for chronic neuropathic pain after traumatic amputation and BPA. This patients records document that standard available treatment options have been attempted without success. Thus, the requested deep brain stimulator is supported as medically necessary for treatment of this patients BPA with neuropathic pain. 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 neurological 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injection series (weekly for three doses to the right knee). This patient presents with a history of osteoarthritis of the right knee. The patients provider has recommended repeat viscosupplementation with Euflexxa injections, which have previously been successful. The presence of osteoarthritis, primarily in the medial compartment and patellofemoral joint, was confirmed on magnetic resonance imaging (MRI) scans. There is an associated complex tear of the body and posterior horn of the medial meniscus. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, there is a history of good response to viscosupplementation on multiple occasions in the past. Furthermore, the patients remaining treatment options are limited. The alternative is a total knee arthroplasty. For these reasons, the requested Euflexxa injection series (weekly for three doses to the right knee) is medically necessary for 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested gene testing (Coagulation factor V) for evaluation of her medical condition.   Findings:  Three physician reviewers found that factor V Leiden testing is recommended in women with venous thromboembolism during oral contraceptive use. In contrast to general screening before administration of oral contraceptives, targeted testing of women with a personal or family history of venous thrombosis is advisable. Routine screening for factor V Leiden in asymptomatic women contemplating or using oral contraceptives is not recommended, except for those with a personal history of thromboembolism or other medical risk factors. In this clinical setting, the patient presented with a strong family history of factor V Leiden mutation.  Therefore, the test at issue was likely to be more beneficial for evaluation of her medical condition than any available standard therapy. Final Result: Three reviewers determined that the testing 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: All three reviewers are board certified in internal medicine with sub-specialty certification in hematology 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 36-year-old female enrollee has requested gastric bypass surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that there is no scientific data that support the required 6 months waiting period. There are no outcome studies that show any benefit of this requirement, short-term or long-term.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 51-year-old female enrollee has requested reimbursement for the inpatient psychiatric hospitalization services. The American Psychiatric Association (APA) guideline states that, hospitalization should be considered for patients who pose a serious threat of harm to themselves or others. This patient posed a serious threat of harm to herself through discharge. The patient reported intermittent suicidal thoughts. She was unable to contract for her safety. Given these findings, discharge prior to the date the patient was discharged would have been premature. The treatment provided to this patient was in accordance with generally accepted standards of medical practice and was clinically appropriate for the patients illness. Thus, the inpatient psychiatric hospitalization services provided were medically necessary for treatment of this patients psychosis and major depressive disorder.Final Result: The reviewer determined that the services at issue were 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 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: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) level of care services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient does not meet Level 3 criteria for RTC services. Applying the ASAM framework, this patient is being treated for opioid withdrawal with buprenorphine. The records documented elevated Clinical Opiate Withdrawal Scale (COWS) scores consistent with moderate withdrawal. The patient reported some difficulty coping with withdrawal discomfort. The patient has no reported comorbidities. The patient endorsed depression and auditory hallucinations. His psychiatric symptoms have not distracted from his recovery efforts. He has been able to participate in group therapy sessions. The provider noted that the patient has difficulty controlling his impulses. The patient willingly entered treatment as a voluntary participant. Due to the chronicity and severity of his substance use, he appears to have limited insight into how his substance usage has affected his ability to cope and function. The patient is currently on buprenorphine 24 mg and he continues to have cravings to use. He relapsed immediately after a prior RTC admission of 30 days. The patient lives with his parents who are both in recovery. His girlfriend does not use substances. Based on these findings, the patient does not meet the criteria for dimensions 2 or 6. Therefore, the RTC level of care services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 with subspecialty certification in addiction 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 a transcutaneous electrical nerve stimulator (TENS) unit for treatment of the enrollees migraines. Findings:  The physician reviewer found that a review of the current medical literature does not support the requested TENS unit for treatment of this patients medical condition. Specifically, a TENS unit is not medically necessary as the effectiveness of a TENS unit for migraines has not been established in the medical guidelines and studies. Moreover, the patient has not reportedly been treated with standard first-line therapies including medications that have been demonstrated to be effective in managing migraine headaches. All told, the requested TENS unit is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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 female enrollee requested platelet plasma injections provided during corrective spine surgery for medical treatment of her disc herniation and foraminal stenosis.  Findings: Three physician reviewers found that the peer-reviewed medical literature fails to evidence that the platelet plasma injections were likely to be more beneficial to the treatment of the patients medical condition than any available standard therapy. In this case, the patient received platelet rich and platelet poor plasma at end of her ACDF. The platelet plasma injections provided were not likely to have promoted improved healing or improved neurologic function of this patient. In addition, medical studies on the use of platelet plasma in spine surgery have not shown improvement of the rate of healing (Carreon, et al; Feiz-Erfan, et al). All told, there is insufficient outcomes data from high quality, well-designed studies to support the use of platelet plasma in this clinical setting. As such, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee requested authorization and coverage for the medication Actiq. The health plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic low back pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Taltz 80 mg/ml. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. While this patient has tried and failed therapy with topical steroids, the medical records do not indicate that standard biologic agents have been used. The documentation submitted does not support a contraindication to the use of the preferred agents. The records show that this patient does not want to use immunosuppressive treatments. However, Taltz is also considered to be an immunosuppressive injectable biologic agent for the treatment of psoriasis. This patient has not tried and failed treatment with Enbrel or Humira. Therefore, Taltz 80 mg/ml is not medically necessary for the treatment of this patients medical condition as there are other preferred therapies available. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in dermatology 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 21-year-old female enrollee has requested bilateral breast reduction and lateral chest liposuction for treatment of her medical condition. Findings:  The physician reviewer found that breast reduction surgery is effective in relieving the symptoms related to large breasts such as back pain, neck pain and skin breakdown if they are present.  In her case, it is not clear that her neck and back pain are due to macromastia as the symptoms have been present since she was 12 years old with an A cup.  The submitted documentation fails to demonstrate the medical necessity of the requested services in her case.  The Schnur scale was developed to relate the amount of  breast tissue removed to preoperative body mass surface area as a means of differentiating cosmetic from medically necessary breast reduction surgery prior to surgery.  In the absence of breast cancer, as the amount of breast tissue removed is increased, the procedure changes from a cosmetic procedure to a medically necessary procedure.  In this case, the proposed removal of 200 grams on the right and 225 grams on the left does not meet the Schnur criteria amount.  The clinical notes do not document shoulder bra strap grooving or intertrigo.  Per the submitted documentation, no abnormal structure of the body is present with respect to the breasts.  The requested surgery will not improve function or turn an abnormal appearance into a normal appearance.  All told, the requested bilateral breast reduction and lateral chest liposuction are not reconstructive in nature and are not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 20-year-old female enrollee has requested ultraviolet light therapy for the treatment of her skin disorder. Findings:  Three physician reviewers found that this enrollee underwent multiple procedures for her acne. The Health Plan has denied coverage for the ultraviolet light therapy provided, and this is the subject of the appeal. The patient was not maximal on her systemic medical therapy. In the absence of documented trial and failure of optimal standard therapies, it has not been established that ultraviolet light therapy was indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for anesthesia (CPT code 00731) administered during the endoscopy procedure received. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether anesthesia (CPT code 00731) administered during the endoscopy was medically necessary for the treatment of the patients medication condition. The American Society for Gastrointestinal Endoscopy (ASGE) Guidelines for sedation and anesthesia in gastrointestinal (GI) endoscopy state the following: We recommend that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. It was also stated that endoscopists use propofol-based sedation (endoscopist-directed or anesthesia-provider administered) when it is expected to improve patient safety, comfort, procedural efficiency, and/or successful procedure completion. Use of propofol in endoscopy procedures is associated with better patient cooperation, shorter recovery periods, higher post-sedation recovery scores, and better sedation than traditional sedation. In this case, the patient had no significant medical history. Her airway score was graded as Mallampati class one. The provider began the EGD procedure under a combination of local anesthetic spray and moderate sedation using fentanyl and Versed. The patient did not tolerate this level of sedation.  In order to complete the procedure safely, the depth of anesthesia was converted to deep sedation with propofol, and the procedure was subsequently completed successfully. The medical evidence supports the services at issue in this clinical setting. Therefore, anesthesia (CPT code 00731) administered during the endoscopy procedure that she received was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology 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.