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

A 61-year-old male enrollee has requested Uroxatral for treatment of his urinary retention. Findings:  The physician reviewer found that the pharmacological approach to the treatment of patients with lower urinary symptoms consists of alpha-1 blockers or/and 5-alpha-reductase inhibitors. The prostate is functionally made up of glandular tissue and muscle tissue. The alpha-1 blockers relax the muscle fibers in the prostate. There are basically two types of these drugs, selective and non-selective blockers. The selective blockers have slightly less effect on muscle fibers seen outside the prostate. The selective blockers include Flomax and Uroxatral.  Clinical studies do not show a significant difference in these two selective drugs. Thus, the Health Plans alternative of Flomax is medically appropriate for this patient. No evidence has been provided that Flomax has been tried without adequate results or that the patient has a contraindication to Flomax. As such, Uroxatral is not clinically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for subcutaneous testosterone implants. Findings:  Three physician reviewers found that the documentation fails to demonstrate the superior efficacy of the services at issue. Any medication that improves serum testosterone to normal range is likely to improve the symptoms if the etiology is strictly the low testosterone. Testosterone replacement was indicated based on the patients laboratory values and symptoms. The medical evidence has not demonstrated that Testopel is more beneficial than other forms of hormone therapy. Thus, subcutaneous testosterone implants were not likely to have been of greater benefit than other available treatment options. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.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: The patient has a history of frequent migraine since her teens. Three to four headache-free days per month were noted. She has tried and failed Topamax, Botox propranolol, Imitrex, Relpax, Lexapro, and gabapentin. The patient was provided Aimovig and had dramatic response with a reduction to two to three headache days per month. The patient has requested coverage for Aimovig. The Health Plan denied the request and stated that the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Aimovig is medically necessary for treatment of this patients medical condition. Calcitonin gene-related peptide (CGRP) monoclonal antibodies are a new class of migraine prevention agents. The only two classes of medications approved by the U.S. Food and Drug Administration (FDA) for chronic migraine are Botox and CGRP monoclonal antibodies. The CGRP monoclonal antibodies have been shown to be highly effective. Studies concluded that Aimovig is an efficacious and well tolerated preventive treatment in adult patients with episodic and chronic migraine. This patient has chronic migraines, has failed three medications from three classes, and had improvement with Botox but still had greater than 25 headache days per month. She has responded well to Aimovig. Therefore, Aimovig is medically necessary for treatment of this patients chronic migraines.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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee was diagnosed with urothelial carcinoma and underwent genomic molecular testing for the evaluation of this patient.  Findings:  The physician reviewers found that the utility of this test is considered experimental in this clinical setting. Therapy and achieved outcomes for urothelial (bladder) cancer are not based on panel testing. These recommendations are well summarized in National Comprehensive Cancer Network Practice Guidelines. Additionally, to demonstrate clinical utility of panel genetic testing, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. There is a lack of such trials currently published. The available literature on its clinical utility consists of a small number of uncontrolled studies, and nonrandomized controlled trials that use imperfect comparators. This evidence is not sufficient to make any conclusions on its clinical utility. In addition, there is potential for harm if ineffective therapy is given based on test results, because there may be adverse effects of therapy in absence of a benefit. As a result, the use of expanded mutation panel testing for targeted treatment in cancer should only be conducted in the setting of a clinical trial. For these reasons, genomic testing (targeted genomic sequence analysis panel) was not likely to have been more effective than the standard therapy available for the evaluation of this patients medical condition. Final Result: Two of three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in medical oncology and 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

A 58-year-old female has requested a replacement ultra lightweight wheelchair for treatment of her rheumatoid arthritis.  Findings:  The physician reviewer found that rheumatoid arthritis is associated with significant declines in functional mobility. The documentation under review indicates that the patient requires a wheelchair to safely perform her MRADLs and that her home will accommodate a wheelchair. The records also indicate that she has significant upper extremity contractures. Given the patients current medical condition, the requested ultra lightweight manual wheelchair is supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for N-acetyl cysteine.Kwo and colleagues state that there are multiple possible etiologies for elevated liver enzymes. According to Heard and colleagues, the use of N-acetyl cysteine (NAc) is recommended in an intravenous fashion for acute Tylenol overdose, generally starting within eight hours. Parvataneni and Vemuri-Reddy indicate that the use of NAc in non-acetaminophen-induced liver failure has also been reported, although it is not supported by clinical trials, and it is of marginal utility in acute liver failure from causes other than acetaminophen poisoning. In this case, the patient has had elevated liver enzymes in the setting of protracted alcohol abuse. The submitted records do not support acute liver failure, and a serologic or histologic workup for causes of liver disease has not been performed. For these reasons, N-acetyl cysteine is not medically necessary for the treatment of the patients medical condition.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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Mekinist for treatment of her medical condition.  Findings:  Two physician reviewers found that there is a lack of support for the requested medication in this patients case.  Mekinist is one of a newer class of drugs.  It has been found to be beneficial when combined with another drug, in the treatment of metastatic melanoma, in patients with a specific BRAF mutation (V600 mutation).  However, there is a lack of published literature relevant to the use of Mekinist in ovarian cancer. In the absence of such data, and also considering that this patient does not appear to have a BRAF mutation, the use of Mekinist is not likely to be of benefit.  Therefore, Mekinist is not likely to be of greater benefit than other treatment options.  Final Result: The reviewer determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Experimental/Investigational
Decision: Overturned

The enrollee requested reimbursement for CustomNext-Cancer 81-gene testing panel. The genetic counselor ordered a genetic testing sample. Literature shows this panel includes 81 hereditary cancer predisposition genes associated with many different types of cancer; including breast, ovarian, prostate, pancreatic, colon, and gastric. Due to her mother's history, she meets criteria for testing of various genes related to the susceptibility to pancreatic cancer. These genes would be reasonable for testing; however, others on the panel would not support a result of improvement in health outcome. The 81-gene comprehensive panel includes genes unrelated to the hereditary predisposition to cancers that have been present in her family.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in clinical genetics 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 52-year-old male enrollee requested authorization and coverage of the medication Lotronex. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees irritable bowel syndrome.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary depending upon the patients fully informed consent and the patients providers registration under the GSK Prescribing Program.
Appeal type: Experimental/Investigational
Decision: Upheld

A 48-year-old female enrollee has requested a magnetic resonance spectroscopy (MRS) for an evaluation of her medical condition. Findings:  Three physician reviewers found that MRS is a technique that is clinically used to study brain tumors and to differentiate those tumors from other lesions and radiation necrosis. MRS has also been widely studied in other neurological disorders in an investigational manner. MRS is not typically used for any diagnostic purposes outside of brain tumors. The diagnosis of MS is usually based on typical MRI findings in association with clinical findings and spinal fluid analyses. MRS has not been shown to be of value in confirming a diagnosis of MS. While MRS is a test with high sensitivity, it has very low specificity and therefore is not effective as a diagnostic tool in this setting.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 14-year-old male has requested approval for anastrozole (Arimidex) for treatment of his idiopathic short stature.   Findings:  The physician reviewer found that although treatment of children who have disorders of growth and adolescent development with aromatase inhibitors, such as Arimidex may be beneficial, data on efficacy and safety are still limited at this time. An increase in predicted adult height has been shown in males with idiopathic short stature (ISS) treated with aromatase inhibitors for at least two years, but few patients have been studied through actual attainment of full adult height. According to the treatment guidelines from the Pediatric Endocrine Society and European Society for Pediatric Endocrinology, The long-term safety and efficacy of aromatase inhibitors in males with ISS has not been demonstrated and long-term follow-up of these patients is still required. Shulman and colleagues noted that, aromatase inhibitors should preferentially be used within carefully controlled clinical trials and that more data on adult heights are needed. All told, safety data regarding bone health, reproductive function, lipid and carbohydrate metabolism, and adrenal function are lacking (Geffner; Maura). Thus, use of Arimidex to improve growth velocity and delay progression in skeletal age in a pubertal boy with ISS is not supported as medically necessary for treatment of his medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested for Aredia for treatment of her osteoporosis. Findings:  The physician reviewer found that there is no evidence that Aredia is a better choice for the treatment of osteoporosis than Boniva, although both medications might be considered second choices. Forteo is often the best choice for preventing fragility fractures. The use of Forteo was originally rejected by the patients provider due to fear of reactivating the patients breast cancer. There is no known clinical basis for that fear. Although Arimidex may have been the appropriate choice at that time, this medication has been shown to increase fracture rates. If it can be demonstrated that the patient is now postmenopausal, a switch to tamoxifen might be considered.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 37-year-old male who has a dsytrophic right first toenail due to onychomycosis verified by fungus culture. The patient has pain and discomfort of his right foot secondary to the onychomycosis. Liver function tests are normal. At issue is whether Lamisil is medically necessary for treatment of the patients medical condition.This patient meets all the medical necessity criteria for oral Lamisil treatment of onychomycosis. The submitted evidence documents consistent clinical features, a positive fungus culture, and symptoms resulting in functional impairment, namely pain and discomfort of the right foot. The absence of a coexisting medical condition should not preclude the use of Lamisil in this case because there is functional impairment, which is likely to worsen if systemic treatment is not instituted. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 17-year-old female with depression and migraine headaches. She reported an increase in the frequency of migraines on her current antidepressant regimen. The patient was evaluated by a neurologist and Botox injections were initiated as a preventative measure. Her neurologist noted a decrease in the frequency of her migraines one month after the first treatment. There is no information in the record regarding the impact of the headaches or the degree of improvement post Botox. The patients father has requested reimbursement for the cost of the Botox therapy provided and continued authorization and coverage for future treatment. The Health Plan denied his requests based on a determination that the therapy is not medically necessary for the treatment of the patients migraine headaches.The patient has migraines and comorbid depression. She has been using Imitrex at a high frequency and preventive therapy is warranted. She may also be having more headaches as a result of her antidepressants. There is no evidence that any preventive regimen was tried before the Botox injections were initiated. In general there is limited evidence establishing that antidepressants have migraine preventive effects, except for the tricyclic antidepressants such as amitriptyline. Multiple preventive medications exist that could be tried, starting at low doses and increasing to a therapeutic level. Preventive medications often take one to two months before they begin to show a benefit. The patient should consider a trial of a tricyclic antidepressant, topiramate, or a beta-blocker.Based upon the information provided, the patient has not exhausted standard medications for the treatment of her migraines. Therefore, I have determined the therapy at issue is not medically necessary for treatment of the patients medical condition. The Health Plans denial of the therapy should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient admission. Reuner and colleagues note that urinary tract infections are a common cause of severe sepsis, and that patients with anatomic urinary obstruction have significantly higher mortality. Yamamoto and colleagues report that acute pyelonephritis (APN) is a common complication of ureteral obstruction caused by urolithiasis and can be lethal if it progresses to septic shock. Sepsis from urinary tract infections may carry significant morbidity and mortality. In this case, given that the patient was at high risk for substantial decline due the presence of fever, leukocytosis, and concern for sepsis, and required treatment with intravenous antibiotics, the service at issue was medically indicated. Therefore, inpatient admission 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 internal medicine with sub-specialty certification in nephrology 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 acupuncture services. The submitted documentation fails to demonstrate the medical necessity of the requested services. In an application for independent medical review, the patient reported that prior acupuncture services assisted in lowering his prostate-specific antigen levels. However, the records do not document the number of sessions already completed and the specific, measurable, sustained, objective, functional improvement obtained with previous acupuncture to support the necessity of the additional acupuncture requested. There is a lack of support for the requested services in this patients case. Therefore, the requested acupuncture services are not medically necessary 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 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

A sixty-three year-old male with a hypodense mass in the body of the pancreas and two small low densities in the liver is requesting reimbursement for a PET scan.  Reviewers Findings:  The reviewing physician found that National Oncologic PET Registry lists the diagnosis, staging, restaging and monitoring of pancreatic cancer as valid indications for PET scan.  The reviewing physician found that the Health Plan denial should be overturned.