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 Harvoni for 12 weeks treatment of the enrollees hepatitis C infection.Findings: The physician reviewer found that according to the 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive, genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication regimen is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of the 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: An enrollee has requested authorization and coverage for surgery to remove cysts for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has a variety of complaints that anatomically localize to a variety of nerve root distributions. These distributions encompass lower lumbar and sacral dermatomal distributions, and some of these symptoms are inconsistent and vague.  Her complaints of urinary incontinence did not yield diagnostically aberrant findings with urological work-up.  The low back and hip pain could correlate with a variety of findings, such as her dysmenorrhea.  Her right leg pain is not isolated to a sacral nerve root distribution and involves at least L5 and possibly L4.  In addition, she has a normal ankle jerk on the right which does not correlate with compression of the S1 nerve root, although its presence does not refute some amount of S1 dysfunction. There is a lack of objective physical findings that point specifically to a right S1, S2 distribution; only subjective findings that involve a capacious amount of dermatomes.  The fact that her symptoms improved somewhat with a selective S2 cyst injection does not necessarily provide significantly useful diagnostic information.  Given the inconsistent, widespread and vague nature of this patients complaints, and the fairly weak support in the literature for specific surgical intervention for Tarlov cysts, the requested surgery to remove cysts is not medically indicated for the treatment of this patient. 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 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral cataract surgical services on an emergent or urgent basis. Findings:  The physician reviewer found that the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the dates in question. In general, clinical situations that may require emergency cataract surgery are phacomorphic and phacolytic glaucoma. In the setting of phacomorphic and phacolytic glaucoma, the lens (cataract) leads to significant elevation in eye pressure. Based on the records, there is no evidence that the patient had these conditions. The patient presented with early cataracts with a lack of evidence demonstrating elevated eye pressure. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe the patient was suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services did not meet prudent layperson criteria for emergency care. Further, it has not been established that criteria for urgently needed services were met. In this case, the patient presented with no signs or symptoms evident of a serious medical condition. The patient underwent cataract surgery of the right eye, and three weeks later the patient underwent cataract surgery of the left eye. The documentation submitted for review fails to demonstrate a condition which cannot be delayed until she returned to the plans service area. The patient did not have an urgent condition such as phacomorphic or phacolytic glaucoma. Based on the documentation submitted for review a prudent layperson in a similar situation would not have believed immediate medical attention was necessary to prevent serious deterioration of ones health.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Motegrity 2 mg daily (QD) for six months. Motegrity is U.S. Food and Drug Administration (FDA) approved for the treatment of chronic constipation. Motegrity has been demonstrated to be safe and effective for the treatment of constipation and associated symptoms, including abdominal pain, with greater efficacy than placebo in randomized controlled clinical trials. The American College of Gastroenterology (ACG) guidelines for constipation recommend the use of advanced laxatives such as Motegrity after failure of stimulant and osmotic laxatives. In this case, the patient has chronic constipation symptoms despite treatment with a stimulant laxative and osmotic laxative. For these reasons, Motegrity 2 mg QD for six months 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 internal medicine with subspecialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parents of an 11-year-old female are requesting authorization for speech therapy for her diagnosis of severe autism with global developmental delay and impairment in all functional areas of language. The patients primary care physician described the patient in June 2005 as `basically non-verbal. The patient has been enrolled in outpatient speech therapy since October 2002. During this period there were two interruptions of approximately 4-5 months each during which the patient was taken to China for alternative therapy (acupuncture). The patient has recently completed a 12-week course of speech therapy and her parents and therapists are requesting authorization for on-going speech therapy in 12-week increments. The Health Plan has denied this request indicating continued speech therapy is not medically necessary for treatment of the patients condition.Review of the submitted clinical information indicates the patient has had several years of twice weekly speech therapy since October 2002. She remains basically non-verbal in the eyes of her primary care doctor. To date, none of the nine goals of therapy that were established have been accomplished. Three of the goals are scored as `not met,` one goal is scored as `partially met` and three goals are listed as `ongoing.` Upon detailed review of the progress report it is evident the patient has not demonstrated significant, sustainable improvement in any of her speech or communication goals and therefore, additional therapy is not likely to have clinical value.Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested chemical dependency residential treatment center (RTC) services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that according to the treatment team notes the patient needed treatment at the residential level of care because he lacked sufficient insight and coping strategies to prevent relapse if discharged. However, subsequently, the patient had made considerable progress in treatment and had changed considerably since admission. The notes indicate that he had gained both insight and coping strategies that would allow him to transition to a lower level of care. In addition, the notes indicate that the family was very engaged and working hard as well. Therefore, the recovery environment was much more conducive toward helping him to maintain sobriety. The patient no longer qualified for the need for 24-hour daily structure and could have been safely treated at a lower level of care. As such, chemical dependency RTC services were medically necessary initially, but not thereafter. 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 partially overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 17-year-old female enrollee has requested for a magnetoencephalography (MEG) for evaluation of the enrollees medically refractory seizures.   Findings:  Two physician reviewers found that the medical literature shows that MEG can assist in localizing epileptic foci, including deep ones that escape standard EEG. It can also help when MRI scans show a lesion discordant to EEG findings, and can map critical normal areas of brain function to optimize surgical planning. It is becoming a generally accepted diagnostic tool at major epilepsy surgery centers due to its ability to allow identification of deep seizure foci.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for treatment of her medical condition. Findings: Three physician reviewers found that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. The American College of Radiology (ACR) has urged tomosynthesis be removed from the investigational category due to the advantages it brings radiologists in the interpretation of both screening and diagnostic mammograms especially in cases of heterogeneously dense tissue as in this case. The tomographic nature of the technique allows radiologists in many cases to separate dense glandular elements from mass or architectural distortion as well as the characterization of indeterminate masses to assess the need for intervention. This has resulted in a decrease in callbacks and increase in detection of small cancers.  Thus, this patient likely had more benefit with the addition of tomosynthesis to her diagnostic study than if she had had two-dimensional imaging only.  Final Result: Three reviewers determined that the services at issue were 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 physician 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: Upheld

A 56-year-old male enrollee has requested Supartz injections for treatment of his knee osteoarthritis. Findings:  The physician reviewer found the submitted records fail to demonstrate the medical necessity of the requested services.  The current medical evidence does not support the requested Supartz injections in this clinical setting.  Rutjes and colleagues performed a meta-analysis of assessing the efficacy of viscosupplementation for adults with symptomatic knee osteoarthritis.  The authors concluded that viscosupplementation is associated with a small and clinically irrelevant benefit, and there is an increased risk of serious adverse effects.  There is a documented incidence of aseptic inflammatory reactions due to allergic response.  Additionally, there is a risk of iatrogenic infection within the joint.  Several studies evaluating repeated treatment protocols document adverse events including inflammatory changes within the knee joint in some cases requiring arthrocentesis after multiple injections.  All told, the requested Supartz injections are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested for removal of orthopedic rods and screws for treatment of her post-surgical pain. Findings:  The physician reviewer found that it does not appear that there has been hardware failure, and there is no documentation that the hardware is producing pain.  There are simply no good indications for the proposed hardware removal outlined in the records available.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old male enrollee has requested authorization and coverage for extracorporeal shock wave therapy (ESWT) for treatment of shoulder pain.  Findings:  Three physician reviewers found that the patient has bilateral shoulder pain and limited range of motion.  The patients recent MRI shows mild acromioclavicular (AC) joint arthrosis and supraspinatus tendonitis. No tears or calcific deposits were noted on the MRI.  There are no supporting documents to denote any failed therapy or clinical notes to document treatments tried, or physical exam or history. The patient has requested authorization for extracorporeal shock wave therapy (ESWT). The Health Plan has denied this request, which is the subject of this review. The literature shows there is some benefit in the treatment of calcific tendonitis with ESWT, however, no calcific deposits were noted on the patients MRI.  Even in patients  with calcific tendonitis, the level of literature support for ESWT is considered low, as there are little to no large scale studies available. Further, there is a paucity of data demonstrating the effectiveness of ESWT in the treatment of joint arthrosis or supraspinatus tendonitis. In addition, no records have been provided to document the patients symptoms and physical limitations or to document that the patient has tried traditional physical therapy with anti-inflammatory modalities without adequate relief.  As such, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested a duodenal switch for treatment of her diabetes mellitus type 2.  Findings:  The physician reviewer found that in this patients case, the submitted documentation fails to establish the medical necessity of a duodenal switch procedure.  A duodenal switch is not medically indicated for patients who do not have clinical severe or morbid obesity at this time.  Low BMI extensions for laparoscopic adjustable gastric banding have been made based upon risk/benefit profile, although this has not been applied for the duodenal switch procedure.  Based upon the current medical evidence, there is a lack of support for a duodenal switch procedure for a patient with a BMI of 30.36.  Per the current National Institutes of Health guidelines, a duodenal switch procedure is not medically indicated for this patient.  I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee requested authorization and coverage of the medication Actiq. The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollees pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the  medication, Xifaxan 200 mg (6 tablets daily for 14 days). The enrollee has diagnoses of small intestinal bacterial overgrowth, dyspepsia, gastritis, and gastroesophageal reflux disease. A progress note reported enrollee symptoms of abdominal pain, but no distention or rectal bleeding. A breath test showed bacterial overgrowth; hydrogen dominant. A progress note reported the enrollee continued to have symptoms of acid reflux and of stomach tenderness after eating. The physician ordered Xifaxan (rifaximin) and for the enrollee to start on Biocidin five days after completing treatment with Xifaxan. Literature reports small bowel intestinal overgrowth is improved with rifaximin. The authors report that 1200 or 1600 milligrams per day rifaximin dosages lead to significant improvement. This enrollee has small bowel intestinal overgrowth and rifaximin has been shown to be beneficial at the 1200 milligrams per day dosage. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old male enrollee has requested for stereotactic radiosurgery for treatment of his pancreatic cancer.   Findings:  Two physician reviewers found that CyberKnife radiation therapy is a very precise method of delivering radiation to a very specific field, and it has been used in a variety of tumor types where such precision is very important. It also has the advantage of entailing a relatively brief period of therapy (1-5 days) compared to more conventional radiation methods. Submitted with the appeal is the data from a Phase I trial wherein 15 patients with pancreatic cancer were treated with this methodology. As a Phase I study, it was mostly focused on the toxicity and feasibility of such treatment, not the long-term results attained. As expected with this cancer, all patients progressed, and the median overall survival was 11 months.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for the Volara System. The Volara System is more likely than other modalities to be beneficial in this clinical setting because it provides both improved lung expansion through positive end expiratory pressure as well as a high frequency oscillatory airflow, which complement  each other. The available current medical literature suggests a benefit from the equipment and supplies at issue. Therefore, the Volara System was and is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the Volara System at issue was and 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 equipment was and is 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 internal medicine with sub-specialty certifications in pulmonary disease and in critical care medicine 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 Dificid 200 mg tablets.According to Infectious Diseases Society of America (IDSA) guidelines, Dificid (fidaxomicin) is recommended for the treatment of Clostridium difficile diarrhea at the dose of 200 mg twice daily for 10 days, either as initial treatment of the infection or as treatment after failure of vancomycin. American College of Gastroenterology guidelines concur that, Oral fidaxomicin 200 mg twice daily for 10 days be used for an initial episode of non-severe Clostridium difficile infection. Fidaxomicin has demonstrated safety and efficacy for the treatment of Clostridium difficile infection. In this case, the patient has confirmed Clostridium difficile infection, and has not responded to vancomycin, which is evidenced by ongoing bloody bowel movements with mucus. Therefore, the requested Dificid 200 mg tablets are medically necessary for 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 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.