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

A 62-year-old female enrollee requested sacroiliac joint fusion surgery for medical treatment of her sacroiliac joint pain.  Findings:  Three physician reviewers found that this patient had objective findings upon examination and had undergone multiple injections with a positive reduction in pain.  However, there is a lack of documentation indicating the patient has exhausted alternate treatment methods.  The peer-reviewed literature indicates that more studies are needed to support the efficacy of the requested surgical intervention.  As such, the requested sacroiliac joint fusion surgery is not likely to be more effective for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 74-year-old male with idiopathic myelofibrosis. He is dependent on blood transfusions for treatment of his anemia. The patient is also on Exjade for iron chelation secondary to transfusion-related iron overload, a potentially life threatening condition. The patients provider recommended treatment with thalidomide (and prednisone) and submitted a request for authorization. The Health Plan denied the request based upon a determination that the medication is not medically necessary.There is no treatment for myelofibrosis that is universally indicated or efficacious in all patients. Myelofibrosis is very heterogeneous and certain therapies work for some patients but not for others. Although thalidomide is not a mainstream treatment for myelofibrosis, there is literature supporting the efficacy of low dose therapy in decreasing the need for transfusions and potential iron overload.  As iron overload is already a major problem for this patient, a three to four month trial of 50mg of thalidomide per day would be reasonable.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: Medical Necessity
Decision: Overturned

A 53-year-old male enrollee has requested a guided (CT/MRI or ultrasound) genitofemoral nerve block for treatment of his pain. Findings:  The physician reviewer found that a review of the literature does not show a prominent role for CT guidance for soft tissue injections into peripheral nervous system structures, although image-guided nerve block utilizing ultrasound would be appropriate. The anesthesia literature shows significant promise for pain procedures into peripheral nerves with ultrasound, as direct visualization can be achieved and a more direct block can be accomplished.  A guided genitofemoral nerve block under direct imaging is likely to be the most beneficial treatment option for this patient. However, CT guidance is not indicated. Per the medical literature, ultrasound has proven to be a good imaging modality without the harmful radiation effects seen in CT or x-ray guidance.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested repair of a power operated vehicle for treatment of her history of joint pain. Findings:  The physician reviewer found that  the submitted documentation fails to demonstrate the medical necessity of the requested services.  Wheelchair prescriptions are best completed using a team-oriented approach, in order to optimize the appropriateness of the device for the given clinical scenario.  In the current case, the patient was assessed in the community by a physical therapist and noted to be able to ambulate in the household with a walker.  She was assessed to have the capacity to self-propel a manual wheelchair.  Her power mobility device was being used for community mobility.  In addition, it was noted that her home was inaccessible to powered mobility.  Overall, the records do not support the medical necessity of ongoing use of a power mobility device such as a power scooter for accomplishing basic mobility-related activities of daily living.  All told, the requested repair of a power operated vehicle is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient hospital stay for treatment of the enrollees abdominal pain. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  This patient had markedly elevated transaminases and clinical signs compatible with acute hepatitis superimposed on chronic hepatitis.  There were no signs of liver failure, although liver failure can develop rapidly due to a number of causes, such as acute viral hepatitis associated with cytomegalovirus, herpes viruses, or Epstein-Barr virus.  Rapid decompensation can result in a need for intensive care, and in acute liver failure with a need for urgent liver transplant.  This patients presentation was also consistent with serious hepatic and gastrointestinal infections more common in patients with immunosuppression.  Given the potential for acute decompensation, ongoing symptoms, and a lack of a clear etiology for the presenting symptoms, inpatient monitoring was medically indicated.  All told, inpatient hospital stay was medically indicated for the treatment of this patient. Final Result: The reviewers 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: Physician reviewer number one 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: Overturned

A 36-year-old female enrollee, who underwent a total abdominal hysterectomy, has requested authorization for the medication Lupron. Findings:  The physician reviewer found that the patient has declined treatment with Zoladex because of concern over having a substance implanted subcutaneously and additional concerns that the implanted capsule will cause activation of her numerous hypersensitivities. Lupron is given as a routine intramuscular injection in either the deltoid or gluteal muscles while Zoladex is administered as a subcutaneous implant with a 16-gauge needle in the abdomen. This difference likely accounts for the fact that Lupron is used much more commonly in clinical practice. The patients objection to implantation of the Zoladex capsule is reasonable, and since the medications are equally effective, Lupron treatment should be considered medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old female enrollee has requested coverage for Pristiq 100mg for treatment of her fibromyalgia. Findings:  The physician reviewer found that the Food and Drug Administration (FDA) for the treatment of fibromyalgia, there are only three medications that are approved for this indication (Lyrica, Cymbalta, and Savella). Pristiq is not FDA approved for the treatment of fibromyalgia, standard practice in the treatment of rheumatology supports the use of off-label medication in the treatment of this disorder.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested an Oncotype DX assay test for an evaluation of her early stage breast cancer. Findings:  The physician reviewer found that Oncotype DX assay is a 21-gene assay that can provide unique biologic information about a patients breast cancer. In node negative women, it has been found to predict the risk of recurrence of cancer without chemotherapy. Additionally, it has been found to indicate whether chemotherapy is likely to benefit the patient. In such patients, it has been widely accepted as standard of care in the oncology community and is within the guidelines of both the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN).  In this case, the patient was node positive. Albain presented the results of his retrospective study that analyzed the predictive ability of Oncotype DX assay in node positive patients. While it did suggest that there may be a role for the assay in such women, the results have not been corroborated and the test is not used by the oncology community to make therapeutic decisions in node positive patients.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program consisting of four days per week treatment with individual counseling once a week, parent support group, alcohol and drug education, addiction education, coping and recovery skills, stress management, random drug testing, and teen group sessions. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral condition.Findings:  The submitted documentation fails to demonstrate the medical necessity for the services at issue in this clinical setting. The patient reported using cannabis at the age of 12. The patients motivation has been decreasing and the patients academic performance had been declining. However, the documentation does not report that the patient was engaging in regular outpatient treatment. The documentation did not report that the patient had failed routine outpatient treatment or failed an outpatient community 12-step program. The records did not demonstrate that the patient had any suicidal or homicidal ideation. The patient had a supportive mother. The records did not indicate that the patient had any medical problems. The patient was attending to his activities of daily living.  Based on the provided record, the patient could have been treated in a routine outpatient setting. The standard of care, in this clinical setting is to treat the patient in the least restrictive environment possible. Accordingly, the documentation indicates that this patient can be treated with routine outpatient services. Therefore, intensive outpatient program consisting of four days per week treatment with individual counseling once a week, parent support group, alcohol and drug education, addiction education, coping and recovery skills, stress management, random drug testing, and teen group sessions were not and are not medically necessary for the treatment of this patients medical condition.Final Result: The reviewer has 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 psychiatry with expertise 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: Urgent Care
Decision: Upheld

A 48-year-old male enrollee has requested for emergency services for treatment of his abscess.  Findings:  The physician reviewer found that according to the prudent layperson standard, an emergency is defined as the sudden onset of symptoms of such severity that a prudent layperson would believe his health to be in jeopardy without immediate medical attention. The wound was packed and antibiotics were prescribed. This patients condition was improving, not deteriorating. The patient did need to be reevaluated in several days for packing removal and to check that the wound was healing properly.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old male enrollee has requested for Botox injections for treatment of her back pain. Findings:  The physician reviewer found that although Botox is not the first line therapy for back spasms, there is certainly literature and science to support its use in select cases that are resistant to other more mainline therapies.  Given that this patient failed previous treatments, and is not a candidate for further surgical methods, and that he responded well to Botox in the past, it is certainly reasonable and medically appropriate to continue therapy with this agent.  Botox is the best available treatment for this patient and has provided relief where other available treatments have failed.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee requested Lipitor for medical treatment of her hyperlipidemia.  Findings:  The physician reviewer found that based on the records provided, the patient presents with a documented intolerance to at least two statin medications prescribed for treatment of hyperlipidemia. Changing from generic atorvastatin to brand name Lipitor does not alter drug metabolism and should not be expected to result in a change in myalgia side effects. Current recommendations also suggest changing to a statin that is less metabolized by cytochrome P450 if myalgia prohibits medication continuation. There is no scientific study that I could find to indicate a difference in tolerability due to myalgia between generic atorvastatin and brand name Lipitor. All told, the request for brand name Lipitor is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Suboxone for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Suboxone is a combination medication containing a partial opioid agonist with a full opioid antagonist.  Suboxone is U.S. Food and Drug Administration (FDA) approved for opioid dependence.  The records indicate that Suboxone has been prescribed for chronic pain.  The current medical evidence does not support the requested medication in this clinical setting.  Other alternatives for pain management are more effective in opioid dependent patients.  All told, Suboxone is not medically indicated for the 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 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: Experimental/Investigational
Decision: Upheld

A 50-year-old female enrollee requested authorization and coverage of extracorporeal shockwave therapy. The Health Plan denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees plantar fasciitis. Three medical professional reviewers performed an experimental/investigational Independent Medical Review. All three medical professional reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three medical professional reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old male enrollee requested authorization and coverage for a referral to a dermatologist for treatment of skin lesions.  Findings:  The physician reviewer found that the patient is requesting coverage for evaluation and treatment of persistent lesions on the extremities. The patient reports having previously been evaluated by a dermatologist and was treated with liquid nitrogen cryotherapy.  The medical records available from his primary care provider do not offer a diagnosis for his current condition.  The primary care provider does recommend evaluation by a dermatologist, which was denied by the Health Plan.  Given that the diagnosis of the current condition is not clear and will not be determined until the patient is evaluated by a dermatologist, the patient does meet medical necessity criteria for a specialty evaluation.  The request for coverage for evaluation by a dermatologist should be authorized for at least one visit, so that an accurate diagnosis can be rendered, given that cure rates of skin cancers are dependent on early diagnosis and treatment (Tuong, et al.; and Tolpinrud, et al.).
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Nuedexta 20/10 mg capsules twice per day, #60 per 30 days for treatment of the enrollees severe head and neck injury occurring after a fall. Findings: The physician reviewer found that in the medical literature, Nuedexta has been demonstrated to be effective for treatment of pseudobulbar affect (PBA). A study noted that PBA is a dysfunction of emotional expression characterized by involuntary outbursts of crying or laughing disproportionate or unrelated to mood, occurring in patients with various underlying neurologic disorders. Another study demonstrated that Nuedexta is supported for treatment of PBA. However, this patients medical records do not document symptoms consistent with a diagnosis of PBA. Accordingly, the requested Nuedexta 20/10 mg capsules twice per day, #60 per 30 days is not 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 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested autonomic nerve and sweat testing for the evaluation of his medical condition.  Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  This patient has had a complex history suggesting a dysautonomia.  Prior test results were thought to have possibly been altered by concurrent medications, and autonomic system testing was performed.  The clarification of diagnosis in a complex case of this sort lead to changes in treatment plans regarding further medications.  All told, the autonomic nerve and sweat testing were likely to have been of greater benefit than other methods of evaluating this patient.   Final Result: Two 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 reviewers are board certified in neurology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Zoll LifeVest. Guidelines of the American College of Cardiology (ACC) recommend use of the LifeVest for patients with left ventricular dysfunction and ventricular arrhythmias at risk for sudden death when an internal cardioverter defibrillator has already been placed and must be removed due to infection. Medical literature shows that overall, studies do not support use of the LifeVest even in patients with left ventricular dysfunction. The researchers reported that the wearable cardioverter defibrillator has not been proven to improve outcomes and more study is needed. Given these findings, the Zoll LifeVest provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the current data from multiple trials and registries have advocated the use of a wearable cardioverter defibrillator after an initial diagnosis of severe left ventricular dysfunction with an ejection fraction of 35% or less.Final Result: Two of the three reviewers determined that the device 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:  One reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. One reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing.  One reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee requested hyperthermic administration of intraperitoneal chemotherapy (HIPEC) for medical treatment of the enrollees ovarian cancer.  Findings:  Two physician reviewers found that the superior efficacy of the requested services has not been established.  The National Comprehensive Cancer Network guidelines do not include the use of HIPEC in their recommendations for post-surgical management of resected ovarian cancer.  Conventional (non-hyperthermic) intraperitoneal therapy is recognized as an option, specifically in cases where surgical debulking was suboptimal.  There is a lack of high-quality prospective trials showing benefit of HIPEC over standard treatment options.  All told, the requested HIPEC is not likely to be more efficacious than other treatment alternatives.