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

A 45-year-old female enrollee has requested Gilenya for treatment of her multiple sclerosis. Findings:  The physician reviewer found that this patient has clinically definite multiple sclerosis. She has highly active disease and requires treatment.  Gilenya is the only currently available FDA approved medication for multiple sclerosis that is oral.  Gilenya is approved for relapsing-remitting multiple sclerosis. This medication has shown a 52% reduction in annualized relapse rate, which is greater than that shown in the pivotal studies of injectable multiple sclerosis drugs.  In this patients case, given this patients highly active disease, the requested medication is medically indicated. All told, the submitted documentation has demonstrated the medical necessity of Gilenya.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 49-year-old morbidly obese female who has an overhanging pannus with treatable intertrigo. The patient wishes to undergo a panniculectomy. She was seen and evaluated by a plastic surgeon who recommended weight loss prior to any procedure. The patient weighed 276 pounds prior to her TAB and bladder suspension in 2002. The submitted notes indicate the patient recently weighed 281 pounds. Additionally, the patient has hypothyroidism and is non-compliant with her thyroid replacement therapy, further adding to her weight problem. The patients intertrigo has responded to appropriate treatment in the past and was not noted to be significant when the patient was evaluated by the plastic surgeon in June 2004. The Health Plan has denied authorization and coverage for a panniculectomy on the basis it is not medically necessary for treatment of the patients medical condition.The submitted medical records and photographs demonstrate a morbidly obese female with a thick abdominal pannus and evidence of intra-abdominal visceral adipose pushing the upper abdomen outward. The possibility of wound breakdown and long-term hospitalization for open abdominal wound infection and possible deep venous thrombosis as well as pulmonary embolus are motivating factors to have the patient lose considerable weight before embarking on a risky procedure. The Health Plans recommendation that the patient lose weight prior to pursuing surgical intervention is an appropriate and reasonable approach for the care of this patient. 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for occipital nerve block for treatment of the enrollee, who has a history of cervicogenic migraine. Findings:  The physician reviewers found that there is sufficient support for the services at issue in this patients case.  Occipital blocks are well accepted as safe and effective for a variety of headache disorders.  The literature shows that they can be valuable for abortive treatment of severe headache, including migraine, cluster, and hemicrania continua. They also have been shown to be valuable as a preventive measure. The patients history supports chronic migraine. Occipital nerve blocks have been shown to be valuable for this condition, and the literature has established their safety. All told, occipital nerve block was likely to have been of greater benefit than other treatment options. Final Result: Two of three reviewers determined that the services at issue were 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 number one, two, and three are board certified in neurology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Foundation One gene test for treatment of the enrollees glioblastoma.  Findings: Two physician reviewers found that the Foundation One gene testing offers a comprehensive panel of molecular genetic markers on an individuals tumor with the hopes of identifying markers than can help guide therapy decision making. The National Comprehensive Cancer Network (NCCN) guidelines have not determined that molecular markers are useful in treatment determination and its use is not addressed for patients with glioblastoma multiforme, other than those with KRAS gene mutation. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy (NCI-MATCH: Targeted therapy directed by genetic testing in treating patients with advanced refractory solid tumors or lymphoma). As genetic testing to guide therapy is the subject of an ongoing phase II clinical trial, the Foundation One gene test has not been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the testing at issue was 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 physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and hematology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Trikafta. Findings:  The physician reviewer found that records provided for review document that this patients cystic fibrosis genotype encodes a truncated W1282X cystic fibrosis transmembrane conductance regulator (CFTR) protein variant, subject to nonsense-mediated decay (NMD) of mRNA transcripts, resulting in insufficient protein production. The patients provider has recommended treatment with Trikafta, which is U.S. Food and Drug Administration (FDA) approved for the treatment of non-F508del cystic fibrosis genotypes. However, due to an absence of response in vitro, the cystic fibrosis alleles W1282X and 2183delAA>G are not eligible for CFTR modulator therapy. Although recent research suggested the functional rescue of W1282X CFTR in patient-derived nasal cultures, these cells were treated with NMD inhibition in addition to protein modulators, which does not establish that the in vitro response was attributed to the effect of protein modulators alone. Overall, there are insufficient evidence to support the use of Trikafta for the management of the W1282X and 2183delAA>G genotype cystic fibrosis. Therefore, the requested Trikafta is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in pulmonary disease and critical care 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 spinal epidural injections for treatment of her medical condition. Findings:  The physician reviewer found that based on the documentation submitted for review, the medical necessity for spinal epidural injections has not been established. According to the documentation, the patient has imaging that is not consistent with radiculopathy. Additionally, the physical exam was not consistent with radicular pain. The peer-reviewed literature supports the utilization of epidural steroid injections in patients with confirmed radiculitis by MRI and physical exam. It is not appropriate to continue treatment with epidural steroid injections in this case where there is lack of documentation to corroborated lumbar radiculopathy. In addition, researchers evaluated the effectiveness of injection therapy for low-back pain.  The literature concluded that there is no strong evidence to support use of injection therapy for non-radicular low-back pain. Given the above, the requested services are not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-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: Upheld

The patient is a 38-year-old female who underwent total knee replacement in December 2003. She received extensive physical therapy throughout much of 2004. Her Health Plan has determined physical therapy was no longer medically necessary as of 6/24/04. The patient is seeking reimbursement for physical therapy she received from 6/24/04 to 10/8/04. The patients physical therapy note from 6/21/04 documents active flexion of 115 degrees with extension of 0 degrees. The patient was independent on six inch stairs and her overall function was not to be very good. At that time, the goal of continued physical therapy was adding strength for the patients overall activities. Physical therapy notes from 8/11/04 and 9/7/04 do not show any improvement in the patients range of motion in extension or flexion. In addition, there is objective documentation to confirm increased strength. Additional records from June 2004 indicate the patient was walking smoothly and was back to work with no problems. Based upon the above information, it is evident the patient could have safely moved to a home exercise/therapy program as of 6/24/04. Therefore, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma genetic testing. Based on the patients American Joint Committee on Cancer (AJCC) stage alone, she had five-year and ten-year melanoma survival rates of 99% and 98%, respectively. The gene expression profiling (GEP) test was subsequently performed and yielded a Class 1a score. Based on the GEP score alone, the patients five-year melanoma specific survival would be as high as 100%, signifying a better prognosis for the patient. At this time, there is a lack of evidence indicating that this information can be used in a clinically meaningful way to benefit the patient, namely, how much less follow-up or screening would be safe for the patient given her current AJCC stage combined with GEP score. In this case, the patient would be a candidate for a sentinel lymph node biopsy, which is recommended for additional staging under National Comprehensive Cancer Network (NCCN) guidelines. The use of the test at the current time is not endorsed and it is not incorporated into the most widely used treatment and management protocols. Therefore, DecisionDx-Melanoma genetic testing was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the DecisionDx-Melanoma genetic testing at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been 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 dermatology 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 23-year-old male enrollee has requested  for continued follow-up with a pediatric cardiologist for treatment of his tetralogy of Fallot. Findings:  The physician reviewer found that adult physicians have not been educated about the complexity of the adult with a congenitally malformed heart. In a field which is so rapidly changing, it is crucial that cardiologists treating adult patients not only have special training, but deal with these complexities on a daily basis to keep abreast of advances in the field. For this patient, the best option may be to eventually transition to such a center. In the interim, or in the absence of an adult congenital cardiologist, it is imperative that this patient with complex heart disease who has had numerous surgeries continue his care with a pediatric cardiologist if an adult congenital cardiologist is not available to him. To require him to see an adult cardiologist who is not specially trained in congenital defects violates the current standard of care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a panniculectomy for treatment of ventral hernia and morbid obesity. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  The records document a complicated case of recurrent ventral hernia in association with a severely enlarged symptomatic pannus.  The patient is well-documented to have signs and symptoms that are likely associated with her severe abdominal pannus.  This includes chronic back pain, abdominal pain, recurrent rashes and open wounds.  The patient has indications for both procedures, as she has a symptomatic severely enlarged abdominal pannus that has failed reasonable conservative management. The panniculectomy approach can provide adequate exposure for the repair of the complex recurrent ventral hernia.  The current medical evidence supports the recommended combined procedure which includes treatment of her complex hernia. 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 plastic 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

The parent of a 12-year-old male enrollee has requested reimbursement for Chemo FX Lab Tests for evaluation of the enrollees telangiectatic osteosarcoma.  Findings:  Three physician reviewers found that the patient has a diagnosis of osteosarcoma. The patient is status post open biopsy. The pathology was consistent with osteosarcoma and the report noted the presence of pleomorphic giant cells throughout the specimen. Also noted were numerous and atypical mitoses and necrosis. This was assessed to be a telangiectatic variant grade IV osteosarcoma. The specimen was sent for evaluation to the Precision Therapeutics laboratory to test the sensitivity of the tumor to chemotherapeutic agents in vitro with the Chemo FX assay. At this time, the Health Plan has denied reimbursement of this diagnostic testing on the basis that it is investigational.At this juncture, the peer reviewed medical literature provides a paucity of data supporting improved health outcomes with use of in vitro chemosensitivity assays. As such, the Chemo FX assay performed in this patients care was not expected to provide novel and helpful information relevant to treatment planning. Further, the assay results in this case only reported what the clinical literature already established. These assays have not been validated and therefore the use of the Chemo FX assay was not likely to be more beneficial than standard therapies in evaluating and treating this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old male enrollee requested a mandibular repositioning device for medical treatment of his obstructive sleep apnea.  Findings:  The physician reviewer found that based on the medical records submitted for review, the patient has known obstructive sleep apnea (OSA). He has been successfully treated with a mandibular advancement appliance since that time. The mandibular repositioning device is effective in treating some instances of OSA, especially in mild to moderate severe cases. Most appliances wear out after two years. Based on the evidence of clinical efficacy, the replacement mandibular repositioning device was medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old female enrollee has requested a short-hinged knee brace for the treatment of her torn medial collateral ligament. Findings:  The physician reviewer found that the requested medial collateral ligament brace is not medically necessary for this patient. The patient was provided a medial collateral ligament (MCL) brace for the diagnosis of a grade 1 sprain.  A grade 1 sprain would indicate tenderness over the ligament, but no instability. The medical records indicate valgus stress as being positive without mention of asymmetry or significant instability on examination. Though bracing may be indicated in some grade 2 and grade 3 injuries, this patient had a relatively mild medial collateral ligament strain which would typically heal without bracing.  There is no indication for bracing in the absence of knee instability, and there was no significant knee instability noted by exam according to the records reviewed.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old male with a history of alcohol dependence, first admitted to residential treatment in 2002 due to consuming a fifth of vodka per day, with corresponding hepatic compromise. He completed seven weeks of residential treatment, continuing in his diversion program thereafter, remaining abstinent for the next 17 months. Thereafter, he relapsed approximately six times prior to his next admission to residential treatment in June 2004, where he remained until July 2004. His most recent use appeared to have been five to six martinis per sitting and he initially submitted his nephews urine for alcohol screening, later submitted his own which tested positive for an alcohol metabolite. The patient had also been treated for post-traumatic stress disorder and for depression (deemed depressive disorder NOS), much of this stemming from his experience in the Iran-Iraq war. He was admitted with previously prescribed Wellbutrin XR and Seroquel, which he continued on while in residential treatment.A request has been made for residential substance abuse services the patient received from June 2004 to July 2004. The Health Plan has denied this request indicating the services at issue were not medically necessary.The patient clearly warranted renewed treatment for his alcohol dependence though his drinking was not nearly as flagrant as appears to have been the case in 2002. The patient was entirely devoid of withdrawal symptoms or particular cravings. In addition, the patient was not afflicted with notable depressive symptoms - his antidepressant medication, for instance, was left at the same dosage as that with which he was admitted. All told, the patients level of acuity did not appear to be such that he could not have been treated at a less intensive level of care, e.g., intensive outpatient treatment or partial hospitalization. Therefore, I have determined that the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 37-year-old female enrollee requested authorization and coverage of extracorporeal shockwave therapy for the treatment of lateral epicondylitis.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that extracorporeal shockwave therapy is not likely to be more beneficial for treatment of the enrollees lateral epicondylitis than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.