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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computed tomography (CT)-guided ablation microwave renal right procedure for treatment of the enrollee, who presented with right renal tumor. Findings:  Two of the three physician reviewers found that the patient was evaluated for abdominal pain by contrast enhanced computed tomography (CT) scan. This scan revealed a small enhancing right renal mass approximately 13 mm. The lesion was highly suspicious for small renal neoplasm. After discussion with her provider, the patient elected to proceed with ablative therapy. The patient requested reimbursement for the CT-guided ablation microwave renal right procedure. The Health Plan denied the reimbursement. Per the Health Plan, the services at issue were investigational for treatment of this patients medical condition. The medical evidence does not support the superior efficacy of CT-guided microwave ablation in this clinical setting. The gold standard treatment option of small enhancing renal masses in otherwise healthy patients is partial nephrectomy. Other options include active surveillance and ablative therapies. There are multiple options for ablative therapies. However, microwave thermal ablation is relatively recent. While the limited studies appear to support this treatment as safe and effective, there is a lack of long-term follow-up to evaluate oncologic outcomes. 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 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 enrollee is requesting authorization and coverage for the medication, Mavenclad (cladribine Tab Therapy Pack 10 MG 10 tabs). The enrollee has a history of multiple sclerosis. The enrollee had used Rebif in the past, but a progress note reports the enrollee described pain throughout her whole body and supersensitivity to her skin after the injection, and she wanted a different medication. The enrollees mother indicates the enrollee is worsening, noting the enrollee awakens weak, demonstrates slurred speech, confuses her words, and continues to experience pain intermittently throughout the day. Records show the enrollees mother reports the enrollee now needs assistance to get around and to go to the bathroom. The physician prescribed a treatment course of Mavenclad oral tablets. Cladribine was approved in the United States by the Food and Drug Administration for the treatment of adults with relapsing forms of multiple sclerosis, including relapsing-remitting multiple sclerosis and active secondary-progressive multiple sclerosis. Because of its adverse effect profile, cladribine is generally reserved for those who do not tolerate or have shown an inadequate response to other drugs for multiple sclerosis. The enrollee has demonstrated an inadequate response and tolerance to other multiple sclerosis therapies. The enrollee has relapsing-remitting multiple sclerosis. Cladribine is beneficial for those with relapsing forms of multiple sclerosis.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 28-year-old female with a history of moderate to severe asthma who has been treated with multiple high dose steroid regimens, long-acting beta agonists, leukotriene modifier, and methylxanthine. She still requires frequent rescue medication. Her last injection of steroids occurred in April 2005. It appears her last use of oral steroids was in August 2005. The patients FEV1 was 1.97 (67%) in May 2006. Her allergic component is treated with diphenhydramine because she experienced angioedema with fexofenadine and loratadine.The patients provider indicates her IgE level was 57 IU/mL in August 2003 and 45 IU/mL in December 2005 and she had a positive skin test. The patient has been previously treated with laser sinus surgery.At issue is whether Xolair is medically necessary for treatment of the patients condition.Review of the submitted clinical information indicates Xolair is medically indicated for this patient. She had a decreased FEV1, elevated IgE, positive hypersensitivity skin test, and has required multiple doses of steroids (oral and injectable). In addition, the patient is on multiple classes of asthma medication, some of which she receives in the form of samples. The patient is an appropriate candidate for Xolair and as such, the medication should be authorized.For the reasons 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for discography of the lumbar spine. Findings:  Three physician reviewers found that there is a lack of support for the requested services in this clinical setting. The conclusions of recent, high-quality studies on discography have significantly questioned the use of discography results as a preoperative indication for either intradiscal electrothermal annuloplasty or spinal fusion. These studies have suggested that reproduction of the patients specific back complaints on injection of one or more discs is of limited diagnostic value. Provocative discography is not recommended because its diagnostic accuracy remains uncertain, false-positives can occur in patients without low back pain, and its use has not been shown to improve clinical outcomes. In this patients case, the rationale for recommending discography testing is not supported by the available medical literature as being predictive for identifying patients who will respond well to surgical treatment. There is reasonable evidence to indicate this test has the potential to cause harm and result in diminished outcomes. Furthermore, a lumbar fusion procedure would not be recommended for this patient who is being treated for non-specific low back pain with lumbar degenerative disc disease. Therefore, discography of the lumbar spine is not likely to be more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are 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 orthopedic surgery 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 authorization and coverage for proton beam therapy, hypofractionation 28 fractions, 80 Gy (CPT 77520, 77522, 77523, and 77525).Currently, there is insufficient clinical data to discern whether treatment with proton beam therapy offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Vapiwala and colleagues performed a multi-institutional analysis of 1,850 patients with low or intermediate risk prostate cancer. The authors compared groups receiving hypofractionated radiation proton therapy and intensity modulated radiation therapy with photons. This analysis found no significant difference in gastrointestinal or genitourinary toxicities between the two treatments. Furthermore, it found no difference in disease control between the two modalities. A position statement released by The American Society of Radiation Oncology (ASTRO) stated, Proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry. At the present time, ASTRO believes the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. The National Comprehensive Cancer Network guidelines endorse the position statement by ASTRO and state that no clear benefit of proton therapy has been demonstrated over standard treatment with photons and intensity-modulated radiation therapy technique. In conclusion, proton beam therapy, hypofractionation 28 fractions, 80 Gy (CPT 77520, 77522, 77523, and 77525) is not medically necessary to treat 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 radiation oncology 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nucynta 100 mg tablet (#120 per 30 days) and oxymorphone extended-release 10 mg tablet (#90 per 30 days). The Centers for Disease Control and Prevention (CDC) guidelines state that, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. The Federation of State Medical Boards guidelines recommend opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective and maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met. The American Society of Interventional Pain Physicians advise providers to establish appropriate physical diagnosis and psychological diagnosis if available. In this case, the patient has tried and failed both pharmacological and non-pharmacologic interventions for management of her pelvic and vaginal pain due to pudendal neuralgia due to traumatic and vacuum assisted vaginal delivery. The patient has been stable and functioning well using a combination of Nucynta and oxymorphone as recommended by her provider. The records document that the patient has not shown any aberrant or drug seeking behavior and that the medications are managing the pain and allowing for the performance of  activities of daily living. In addition, there is no documentation showing that there has been any irregularities in the CURES report and there are no inconsistent urine drug screens documented. Based on these findings, the requested Nucynta 100 mg tablet (#120 per 30 days) and oxymorphone extended-release 10 mg tablet (#90 per 30 days) are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medications 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 anesthesiology with subspecialty 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Protopic (tacrolimus) 0.03% ointment. Tacrolimus is a topical calcineurin inhibitor (TCI). A study noted that evidence on the use of TCIs for infants has almost exclusively been collected for pimecrolimus and has consistently confirmed that pimecrolimus is a safe and effective treatment for infants with atopic dermatitis. The authors concluded that after a careful review of the available evidence of clinical trials, post-marketing surveillance, and epidemiological studies, the TCI pimecrolimus offered a safe and effective alternative to topical corticosteroids in infants aged three months and above. In this case, the patient has persistent facial atopic dermatitis and has tried and failed hydrocortisone and triamcinolone. Given that current medical literature supports the safety and efficacy of TCIs for the treatment of atopic dermatitis, and as the provider has recommended a TCI to prevent flares and minimize side effects, the requested medication is medically indicated. Therefore, Protopic (tacrolimus) 0.03% ointment is medically necessary to prevent disease, disability, and other health conditions or their progression.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 dermatology 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Durolane injection in the right knee. An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. Guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where everything else has been tried and the options are limited. In this case, there is documentation of osteoarthritis of both knees, right greater than left. Conservative treatment, including NSAIDs, opioid medications and a cortisone injection, have been tried. Arthroscopic surgery was also tried and failed. There is sufficient support for the requested service in this clinical setting. Therefore, the requested Durolane injection in the right knee is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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: Upheld

The son of a 69-year-old female enrollee requested authorization and coverage for 24-hour home hospice care.  The health plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees cancer. 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Ocaliva. Medical guidelines recommend increasing Ocaliva from 5 mg to 10 mg if a patients alkaline phosphatase remains persistently elevated. These findings are consistent in the current peer-reviewed published literature. Further, the U.S. Food and Drug Administration (FDA) prescribing information for Ocaliva does not recommend stopping therapy based on alkaline phosphatase and bilirubin response. In this case, bilirubin is not an accurate metric for response as the patient has Gilberts syndrome. For these reasons, the request for Ocaliva is supported as medically necessary for the treatment of the patients primary biliary cholangitis.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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee requested a 12-week course of Zepatier for treatment of the enrollees chronic hepatitis C virus.  Findings: The physician reviewer found that according to the 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 should be treated except those with limited life expectancy due to non-liver related conditions. The guidelines recommend that treatment naive genotype 1b patients should be treated with Harvoni for 12 weeks or Zepatier for 12 weeks. These guideline recommendations are based on high-quality clinical trials for Harvoni and for Zepatier (Kowdley, et al; Afdhal, et al). However, there are no controlled direct-comparison trials showing that Zepatier is safer or more effective than Harvoni for treatment of genotype 1 hepatitis C. Per the AASLD/IDSA guidelines; they cite data showing reduced survival with delayed treatment (Jezequel, et al). While treatment for this patients hepatitis C virus is medically necessary, the requested 12-week course of Zepatier is not medically necessary unless treatment with Harvoni is unavailable.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 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: Upheld

A 49-year-old male enrollee requested STAR ankle replacement surgery for medical treatment of his left ankle traumatic arthritis. Findings:  The physician reviewer found that based on this patients history including distraction arthroplasty, arthroscopic debridement of the ankle, and a history of osteomyelitis, a total ankle replacement is not medically appropriate. Given the information submitted for review, peer-reviewed literature, and clinical expertise, the medical necessity for a STAR ankle replacement surgery is not established. In the medical literature, Schuh and colleagues concluded that the use of a total ankle replacement versus arthrodesis is not proven to be significantly superior in treating patients with severe ankle arthritis. The documentation submitted for review does not support the patient as a good candidate for a total ankle replacement. Further, as the long-term efficacy of the requested procedure is not established, the medical necessity for a total ankle replacement is not established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for a foam roller. Physical therapy can be important in the initial stages of a rehabilitation program for rotator cuff issues and other shoulder conditions. However, based on the current medical literature, there is a lack of data supporting a role of foam rollers for these types of conditions. Although this patient may have persistent symptoms, there is no indication for the requested equipment for treatment of his medical condition. All told, the requested foam roller is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation 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 62-year-old female enrollee requested authorization and coverage of a referral to a nephrologist for the treatment of chronic kidney diseasea.  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.