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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for onabotulinumtoxinA (Botox) injections every three to four months for the duration of one year for treatment of the enrollees neck pain.  Findings:  The physician reviewer found that Botox A has been used for myofascial pain with some recent evidence. However, most of the clinical evidence does not support or is inconclusive for the use of botulinum toxin for myofascial pain. In this patients case, not all non-botulinum toxin treatment options have been utilized or documented. While pain psychology group therapy was noted to be done for mood control, there was no mention of individual behavioral therapy for pain, in the form of cognitive behavior therapy or bio feedback, despite much research to support its use. In addition, the submitted documentation does not indicate that all non-botulinum toxin medications have been optimized or documented to be done. Moreover, the treating providers offered interventional treatments for this patients pain. It was noted in the past that the pain source may be the facet joints, which has great research to support treating facet pain with injections and/or radiofrequency ablation.  Based on the records and medical literature, not all evidence based interventional treatments have been tried for treatment of this patients pain. For all these reasons, the requested authorization and coverage for Botox injections every three to four months for the duration of one year, has not been demonstrated as medically necessary for treatment of this 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 anesthesiology 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: Medical Necessity
Decision: Overturned

A 65-year-old male enrollee has requested for Hyzaar 100/25 for treatment of his hypertension. Findings:  The physician reviewer found that this medication is indicated and medically appropriate. Per Milliman Care Guidelines, Hyzaar is indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene testing for evaluation of anemia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue. A review of the medical literature finds that while there are reported associations of MTHFR polymorphisms with several conditions, there are very limited clinical indications for testing for polymorphisms in the MTHFR gene, as these associations have not been shown to have clinical significance.  In addition, there is scant evidence for the use of this genetic test in the evaluation of folate and/or vitamin B12 deficiency. All told, gene testing was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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: Reviewers 1, 2 and 3 are board certified in internal 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

A 51-year-old female enrollee requested authorization and coverage of the medication Vioxx. The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollees bursitis and degenerative joint disease.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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for inpatient treatment for radioactive iodine therapy. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees thyroid cancer.At issue in this case is whether the requested inpatient treatment for radioactive iodine therapy is medically necessary for treatment of the enrollees medical condition.The patient has metastatic thyroid cancer. She is status post thyroidectomy. She will be receiving remnant thyroid ablation with high dose (90 mci) I-131 therapy. A study note that regulatory requirements for hospitalization and other radiation protection vary among states and countries with many guidelines being more stringent than those of the Nuclear Regulatory Commission. Most states require inpatient stay if the I-131 dose exceeds 30 mci of I-131. The patient was evaluated by a nuclear medicine radiologist who has recommended that the subject be treated with I-131 therapy as an inpatient in a special room. Given the high dosage of radiation (90 mci), the inpatient level for the radioactive iodine-131 ablation for metastatic thyroid cancer is medically necessary.Final Result: The reviewer determined that the requested treatment 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 endocrinology, diabetes and metabolism 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 51-year-old female enrollee requested authorization and coverage of BRCA1 and BRCA2 genetic testing. The Health Plan denied the request indicating that the requested services are not medically necessary for evaluation of a possible prophylactic oophorectomy.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee requested authorization and coverage for an MRI. The health plan has denied this request indicating that the requested MRI is not medically necessary for treatment of the enrollees 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 requested MRI is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 36-year-old male enrollee has requested a specialty referral to a hand specialist for treatment of his left thumb injury.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested service in this clinical setting.  The medical records note the presence of a negative x-ray.  However, this does not rule out the need for evaluation by a hand specialist.  The patient may have instability at either the radial or ulnar collateral ligament of the metacarpophalangeal joint of the left thumb.  If there is clinical instability, there is a need for surgical repair, and this assessment is best provided by a hand specialist.  The current medical evidence supports the requested service in this case.  All told, the requested specialty referral to a hand specialist is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old male enrollee has requested a morphine pump for the treatment of his chronic pain. Findings:  The physician reviewer found that morphine and ziconotide, a calcium channel blocker, are the only drugs approved by the FDA for intrathecal infusion for pain. Review of the literature includes several peer-reviewed published studies that document the efficacy of an intrathecal infusion system for pain management. Doleys, et al. reported better pain relief with intrathecal opioids versus oral opioids in a paper published in 2006. Kumar, et al. reported an increase in daily activities in patients with intrathecal pumps after years of leading passive lives. Tutak and Doleys documented a decrease in the use of oral opioids twelve months after pump implantation. This patient appears to be a good candidate for pump implantation. He underwent a successful trial and has received psychological clearance. Most importantly, his current medication regime is not providing adequate pain analgesia.
Appeal type: Experimental/Investigational
Decision: Upheld

A 43-year-old female enrollee has requested for insulin potentiation therapy for treatment of her poorly differentiated infiltrating ductal carcinoma of the left breast.   Findings:  Three physician reviewers found that there is no evidence that it provides clinical benefit superior to available standard therapies. There is a lack of peer-reviewed literature to support insulin potentiation therapy for treatment of this patients condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the bilateral digital breast tomosynthesis for evaluation of the enrollees breast cancer evaluation. Findings:  Two physician reviewers found that the patient is a asymptomatic who underwent a screening mammogram including tomosynthesis. The exam revealed no changes compared to previous studies. The patient has requested reimbursement for the bilateral digital breast tomosynthesis. The Health Plan has denied this request as investigational. The American College of Radiology (ACR) has urged tomosynthesis be removed from the investigational category due to the advantages it brings radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two-dimensional (2D) imaging alone. Thus, the addition of tomosynthesis to the usual 2D protocol was likely of greater benefit to the patient than had her exam been done with 2D imaging only. Accordingly, the bilateral digital breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the 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 reviewers are board certified in diagnostic radiology 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

The patient is a 12-year-old male who was diagnosed with ADHD and requires growth hormone supplementation. He has been under the care of a psychiatrist for several years and has taken the following medications: Dexedrine, Concerta, Adderall, Strattera, Wellbutrin and Tenex. The patients provider described the indications and the reasons for discontinuing each of the medications prescribed in an attempt to control the patients ADHD. The patients provider also noted concerns related to small stature, the impact of stimulants on growth and the need for growth hormone supplementation. The provider initiated an off-label trial of Provigil and found that the patient tolerated the medication well and had a remarkable clinical response. The provider requested authorization and coverage for Provigil, but the request was denied by the Health Plan based upon a lack of medical necessity.A significant number of medications utilized for children are off-label. Antidepressants are one example.  Prozac is a rare exception to the general rule that there are very few non-off-label antidepressants for children. Multiple other antidepressant medications are prescribed by physicians despite their off-label status. There is a clear precedent for the off-label use of a medication for children and adolescents. In this clinical context, there is a well-founded rationale for not utilizing standard medications to treat the patients ADHD and there is clear documentation that the patient has responded well to Provigil without untoward side effects. Additionally, a review of the literature does reveal support for the use of Provigil and its effectiveness in treating children with ADHD. Based upon the information set forth above, 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genetic testing called Foundation One for the evaluation of her recurrent metastatic clear cell uterine cancer. Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting. Adenocarcinoma of the endometrium (lining of the uterus) is the most common type of uterine cancer. This patients pathology was consistent with a serous-clear cell morphology. Serous is the second most common histology of endometrial cancer whereas clear cell is uncommon. Both of these histologic types are associated with a worse prognosis and frequently present with extrauterine disease at the time of diagnosis. Serous and clear cell endometrial cancers are not stimulated by estrogen and have a different genomic profile when compared to typical endometrioid carcinomas. Serous tend to demonstrate human epidermal growth factor receptor 2 amplification and p16 alterations. Clear cell carcinomas tend to have a tumor profile more akin to clear cell carcinomas of the kidney than endometrioid carcinomas. In this patients case, she presented with an aggressive uncommon histologic type of endometrial cancer, serous, clear cell, and sarcomatoid. The literature at this time suggests that molecular genotyping of these tumors will help better characterize the phenotype, prognosis and therapeutic options. Although most of the molecular therapeutic options are not a standard of care, the use of somatic genotyping in this case further clarified phenotype and prognosis. The thorough analysis preempted the use of Herceptin given other molecular characteristics that suggested likely resistance. Final Result: The 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty 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: Overturned

A 20-year-old female enrollee has requested for residential treatment for treatment of her anorexia nervosa.  Findings:  The physician reviewer found that she presented with serious manifestations, including purging, restricting, overexercising, amenorrhea, bradycardia, orthostasis, dizziness, elevated LFTs, episodes of self harm, and significantly stressful family dynamics.  While the patient had experienced some improvement, she was not appropriate for discharge from residential treatment level of care at that time. Continued treatment was needed to prepare the patient for a step-down in level of care. It was essential for the patient to participate in a therapeutic home pass to determine stability for discharge. The transition from the safety and containment of residential treatment to being an outpatient is difficult at best. The importance of a careful assessment of a patients ability to manage a pass out of the hospital, and scrupulous discharge planning cannot be overemphasized. The chances of a patient's enduring success are significantly bolstered when these critical junctures are given adequate time and attention.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female enrollee has requested bilateral breast reduction for treatment of her symptomatic mammary hypertrophy.  Findings:  The physician reviewer found that the American Society of Plastic Surgeons (ASPS) has guidelines for determination. The ASPS state that, based on the results of level I and II evidence, reduction mammaplasty has been proven effective at reducing macromastia related symptoms and improving postoperative quality of life. Based on the patients complaints of upper back, neck and shoulder pain, and shoulder grooving, photographs documenting severe macromastia and shoulder grooving as well as her examination detail satisfies these guidelines established by ASPS. Her breast macromastia had impacted her quality of life and she has chronic back and neck pain and shoulder grooving that has failed non-operative management.  Her photographs support these findings as well. Based on this, her condition of macromastia is causing functional problems and would likely benefit significantly from reduction surgery. Further, the patient has an abnormal appearance as seen in the photographs and breast reduction is well-known to establish a relatively normal appearance. Her entire clinical picture is one of a functional problem, but her appearance would be significantly improved as well. The planned procedure is for improving function related to significant pain of the back, neck and shoulders as a direct result of the well-documented macromastia. Consistent with these findings, the requested surgery is reconstructive in nature and medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee has requested a biopsy of fluid from the left ear; and a non-invasive procedure (tubes) whereby fluid is drained from left ear for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. Myringotomy and tube is a medically necessary procedure for the treatment of Eustachian tube dysfunction or persistent middle ear effusion. The medical records provided for review indicate that this patients primary issue is recurrent attacks of vertigo, which are central in origin and likely related to a migraine etiology. Thus, the request for a biopsy of fluid from the left ear and a non-invasive procedure (tubes) whereby fluid is drained from left ear is not medically necessary in this clinical setting. Moreover, placement of a tube in the ear will not help his condition and is not medically necessary. Based on the medical literature cited above and the documentation submitted for review, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested ChemoFx assay for treatment of her recurrent abdominal wall sarcoma.  Findings:  Three physician reviewers found that in vitro drug testing on an individual patients tumor cells prior to applying chemotherapy is an attractive idea, but difficult to put into clinical use. The most thorough evaluation of these technologies was performed by the American Society of Clinical Oncology (ASCO) in 2004. In their thorough review of this technology, ASCO concluded that such in vitro drug testing should be limited to clinical trials. All told, the ChemoFx assay was not likely to have been more beneficial for evaluation and treatment of this patients medical condition than standard therapies.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 42-year-old female with a body mass index (BMI) of 58 with multiple obesity related comorbidities. She has failed medical management and now wishes to pursue operative treatment. She has not had prior surgery. The patient has requested authorization and coverage for laparoscopic adjustable gastric banding (Lap-Band) surgery.  The Health Plan has determined the patient can be appropriately treated with Roux-en-Y gastric bypass. Current scientific literature does not demonstrate that Lap-Band surgery results in any clear benefit for any specific group of patients. Most of the scientific data available have small numbers, short-term follow-up, and unacceptable success rates. The greatest expected weight loss with Lap-Band is 50% to 60% at three to five years out. A patient with a BMI of 58 will still be obese with a 50% weight loss. Thus, gastric banding is less efficacious than alternative weight loss procedures and is not indicated in this case. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.