Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees adenocarcinoma of the lung.Findings:  Two of the three physician reviewers determined the National Comprehensive Cancer Network guidelines note that broad molecular profiling is advised to identify rare driver mutations for which effective drugs may be available or to counsel patients regarding clinical trials. In this patients case, the initial therapy was based on the presence of the EGFR mutation.  Second-line treatment in that setting, would have been based on whether there was a T790M mutation.  The medical evidence supports T790M and BRAF components of the test, and the records indicate that these particular components were covered by the Health Plan. However, the superior effectiveness of the remaining testing has not been demonstrated. Thus, Guardant360 was not likely to have been more effective 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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 perineorrhaphy and surgical repair of the vagina for treatment of the enrollees recurrent perineocele. Findings:  The physician reviewer found that based on the available documentation, specifically the providers notes, the patient continues to have a bulge in the perineum consistent with weakness in the area of the perineal body/distal rectum. This leads to persistent need for splinting to defecate associated with narrowing of the vagina and resulting dyspareunia. Given the patients persistent symptoms, further evaluation and surgical management of the patients persistent symptoms is considered a safe and appropriate next step. Thus, the requested perineorrhaphy, using the procedure recommended, surgical repair of perineocele, using the procedure recommended, and surgical repair of the vagina, using the procedure recommended is supported as medically necessary for treatment of this patients recurrent perineocele. 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 urology 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: The patient has requested reimbursement and prospective authorization and coverage for Repatha Pushtronex system. Findings: The American College of Cardiology takes note of non-statin therapies for lowering His low-density lipoprotein (LDL) cholesterol for the management of atherosclerotic cardiovascular disease risk. In higher risk patients with clinical atherosclerotic cardiovascular disease or familial hypercholesterolemia, alirocumab and evolocumab (brand name Repatha) may be considered if the goals of therapy have not been achieved on maximally tolerated statin and ezetimibe. In this case, the records do not document that the patient has been unable to achieve an LDL goal of under 70 mg/dL while taking the combination of maximally tolerated statin plus ezetimibe, or that the patient is unable to tolerate these drugs. In this clinical setting, the submitted records do not document that the medication at issue was and is medically indicated to manage the patients hypercholesterolemia. Therefore, Repatha Pushtronex system was not and is not medically necessary for the 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 internal medicine with sub-specialty certification in cardiovascular disease 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 63-year-old male has requested continued skilled nursing care and rehabilitation services for treatment of his acute pancreatitis, hypertension, and end-stage kidney disease.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  As of the date at issue the patient had plateaued with daily skilled therapy services.  He was stable on his medical regimen.  The patient was tolerating a full diet, and he had no complex wound care issues.  The documentation noted that the patient was able to ambulate 75 feet with a four-wheeled walker with stand by assistance, and he was able to transfer with stand by assistance.  He was stable with his activities of daily living.  Per the medical records, there is no medical indication for continued daily skilled nursing or therapy needs at this time.  The documentation does not demonstrate that the patient was expected to make any further measurable gains in a predictable period of time with continued skilled nursing services.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for back surgery (including CPT codes 22558, 22585, 22612, 22614, 22842, 22845, 22853, 49010, 20936, 20931, and 76000). Wood and colleagues recommended that fusion should be considered for patients with low back pain and isthmic spondylolisthesis who have failed non-operative treatment. Researchers support surgery for spinal stenosis in patients who do not improve with conservative treatment. The authors noted that the inclusion of fusion is recommended for patients with demonstrated spinal instability or the likelihood of iatrogenic instability. Studies concluded that the body of literature supports fusion surgery as a viable treatment option for reducing pain and improving function in patients with chronic lower back pain refractory to nonsurgical care in the setting of disc degeneration. This patient presents with progressively worsening back pain radiating to the right lower extremity with numbness, tingling and weakness. She has reported bowel and bladder changes. Overall, the patients signs and symptoms are consistent with neurogenic claudication. Clinical examination findings have documented a significant motor deficit consistent with imaging evidence of severe L4-5 central canal stenosis with crowding of the nerve roots and thecal sac, and severe facet arthrosis at L5-S1 with foraminal stenosis and moderate degenerative disc disease. There is radiographic evidence of spondylolisthesis at L4-5 measuring 3-5 mm and L5-S1 measuring 12-15 mm with documented spinal segmental instability on flexion and extension x-rays. The patient will likely require a wide decompression that would result in temporary intraoperative instability and necessitate fusion. Evidence of a long-term reasonable and comprehensive non-operative treatment protocol trial and failure was provided for review. Current evidence based medical literature supports surgical intervention for the treatment of this patients spinal stenosis, degenerative disc disease, and unstable spondylolisthesis. In the setting of L4-5 and L5-S1 spondylolisthesis with documented spinal segmental instability, the need for wide decompression would likely result in temporary intraoperative instability and necessitate fusion. Given these findings, the requested back surgery (including CPT codes 22558, 22585, 22612, 22614, 22842, 22845, 22853, 49010, 20936, 20931, and 76000) is medically necessary for 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: Medical Necessity
Decision: Overturned

A 53-year-old female enrollee requested authorization and coverage of continued partial hospitalization for the treatment of depression.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for medical treatment of her chronic hepatitis C virus.   Findings:  Two physician reviewers found that according to the most recent 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, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. These new guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic genotype 1 hepatitis C regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). Treatment of genotype 1 hepatitis C is recommended with daily Harvoni. Moreover, interferon-based regimens are no longer recommended for first-line therapy. Based on the provided records, published evidence of safety and efficacy in the published literature and clinical guidelines, the requested Harvoni should be approved as medically necessary for treatment of this patients medical condition.   Final Result:  Two reviewers have 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition, knowledgeable about the proposed treatment, and familiar with guidelines and protocols in the area of the treatment under review.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested high intensity focused ultrasound for ablation of prostate tissue for treatment of the enrollees prostate cancer. Findings: Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  Both high intensity focused ultrasound and focal therapy have been increasingly used for treatment of localized prostate cancer within the last decade.  These treatments have the theoretical potential of decreasing gastrointestinal, genitourinary and sexual toxicity.  The available literature mainly consists of prospective case series and retrospective studies showing short-term outcomes for localized prostate cancer.  There is a lack of controlled trials available for analysis, and a lack of long-term survival data is available.  There are no validated biochemical and surrogate end-points for cure.  Therefore, high intensity focused ultrasound for ablation of prostate tissue is not likely to be superior over other treatment options.Final Result: Three reviewers determined that the services at issue are 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 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: Upheld

 Nature of Statutory Criteria/Case Summary:   An enrollee has requested oxycodone APAP for treatment of his chronic knee pain, osteoarthritis, and lumbar spine degenerative disc disease. The physician reviewer found that the available medical records provided for review do not support a continuation of opioids for this patient. The medical records demonstrate high risk behavior for adverse event which constitutes a potential safety issue. Moreover, combination with alcohol is a relative contraindication for opioid therapy. Provenzano and Viscusi noted that opioids exhibit a well-established abuse potential and evidence supporting the efficacy of opioids in chronic pain management is limited. In addition, opioid exposure is associated with adverse effects on multiple organ systems. Cheung and colleagues found that multiple current published guidelines suggest that opioid use should be limited in patients that demonstrate high risk behavior including failure to follow opioid consent agreements, aberrant use of opioids or concomitant use of alcohol. Nuckols and colleagues reported that recent guidelines on chronic pain agree on several opioid risk mitigation strategies, including upper dosing thresholds, caution with certain medications, attention to drug-drug and drug-disease interactions, and use of risk assessment tools, treatment agreements, and urine drug testing. All told, the medical records do not support the medical necessity of the requested oxycodone APAP 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 neurology 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: Experimental/Investigational
Decision: Overturned

The parent of an 11-year-old female enrollee has requested  for a magnetoencephalography (MEG) with MRI of the brain for evaluation of the enrollees seizure disorder.   Findings:  Three physician reviewers found that the patient has a complicated cerebral architecture that is distorted by tuberous sclerosis and her prior operation.  In order to maximize the success for her subsequent surgery, MEG with MRI is required. There is adequate literature to support the use of MEG/MRI during selected circumstances.  One such circumstance is for children with tuberous sclerosis and intractable epilepsy. This patient meets those circumstances.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: he enrollee has requested authorization and coverage for Xeljanz XR (extended release) for treatment of the enrollees rheumatoid arthritis.Findings:  The physician reviewer found that the 2015 American College of Rheumatology (ACR) Guideline for treatment of rheumatoid arthritis recommends methotrexate (MTX) with or without tumor necrosis factor inhibitor (TNFi) as the next treatment option in patients who have failed MTX alone.  There is evidence that a second TNFi is effective in those who have tried and failed a previous TNFi or have had adverse reactions to other TNFi. In this patients case, the documentation provided indicates failure of multiple disease-modifying antirheumatic drugs. Previous treatments have included methotrexate 17.5 mg, which was stopped in February 2017 because the patient was not able to tolerate the therapy. Plaquenil and Humira were partially effective, but the patient has a fear of needles. The patient has an allergy to Remicade. Actemra and Orencia were also ineffective. The patient has been on Xeljanz since February 2017 with one tender/swollen joint, normal DAS28erythrocyte sedimentation rate/Creactive protein and low disease activity. The record is clear that this patient has tried and failed two different TNFi (Humira and Remicade). The patient has also failed two non-TNF biologic agent as recommended by 2015 ACR guidelines (Orencia, Actemra).  During her April 2017 evaluation, there was improvement in her symptoms but her examination remains unchanged. As such, Xeljanz XR is medically necessary. 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 rheumatology 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

A 31-year-old female enrollee has requested a magnetoencephalography (MEG) for evaluation of her seizure disorder. Findings:  Three physician reviewers found that compared with other modalities of epilepsy mapping, MEG provides the best temporal and spatial resolutions, without the invasiveness. MEG is no longer considered experimental and is essential for the presurgical evaluation of patients with epilepsy, especially those with a negative PET scan. Accurate lateralization of her epiletiform events is crucial for this patient and MEG is the most appropriate study to accomplish this.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested  speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that this patients speech is below the level of a one-year-old peer, thus this patients speech is significantly delayed as well documented by formal testing. The etiology is due to a severe developmental delay in the maturation of speech due to motor apraxia. His brain development has been delayed altering and disrupting cerebral input to the muscles of the jaws and oral pharyngeal musculature. Speech apraxia is a well-known neurological disorder as acquired phenomena in adult stroke patients. In this particular patient, the apraxia is congenital, not acquired. Overall, the patients score on the Kauffman subtest was -1.5 standard deviations below the 7th percentile. From the available information, the patient is likely intellectually normal, but presents with an expressive speech delay due to apraxia, as there is no history of any prior developmental evaluations when his speech was evaluated. Given that this patient is two-years of age and currently exhibiting the skills of a one-year-old peer and there is robust medical literature supporting speech therapy in this speech delayed population, the requested therapy should be approved.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for applied behavioral analysis (ABA) assessment and direct 1:1 ABA, 12 hours per week for 3 months, and then 6 hours per week for 3 months; parent and caregiver training, 8 hours per month for 6 months; case management/supervision, 8 hours per month for 3 months, and then 5 hours per month for 3 months; assessment/indirect treatment planning 5 hours per month for 3 months, and then 2.5 hours per month for 3 months. ABA encompasses a wide-variety of techniques commonly used in the treatment of ADHD, oppositional defiant disorder, conduct disorder, and various anxiety disorders. More specifically, behavioral management training is an evidence-based treatment for problem behavior supported by extensive research for children diagnosed with ADHD and disruptive behavior disorders (Kazdin, et al.). Further research in this area indicates that behavioral treatments produce reliable and significant reductions in oppositional, aggressive, and antisocial behavior among children with behavior disorders (Kazdin, et al.). Based on this support, along with the growing breadth of research demonstrating the successful use of ABA therapy in the treatment of disorders other than autism, ABA is an appropriate treatment modality to address this patients behavioral health issues. Additionally, given the patients documented history of success with ABA therapy, ABA is the most effective available treatment for the patients diagnoses, even when compared to any available treatment modality. Therefore, the ABA assessment and direct 1:1 ABA, 12 hours per week for 3 months, and then 6 hours per week for 3 months; parent and caregiver training, 8 hours per month for 6 months; case management/supervision, 8 hours per month for 3 months, and then 5 hours per month for 3 months; assessment/indirect treatment planning 5 hours per month for 3 months, and then 2.5 hours per month for 3 months, provided from 1/1/19 and forward, were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were and are 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:  One reviewer is a licensed B.C.B.A, board certified in psychology and is actively practicing. One Reviewer is a licensed B.C.B.A, board certified in psychology and is actively practicing.  One Reviewer is a licensed B.C.B.A, board certified in psychology and is 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.