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

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for oxycodone-acetaminophen tablets. The Health Plan has denied this request indicating that the medication at issue was not medically necessary for treatment of the patients chronic, open wound of the left ankle. The medical needs of the patient and medical literature supports the medical necessity of the medication at issue. In this patients case, the prescriptions were medically reasonable and necessary. Researchers clearly state that the use of Percocet (oxycodone-acetaminophen) is appropriate in the peri-operative period for pain relief. Similarly, other researchers mention that narcotics are frequently used for pain post-operatively. This patients case has nothing to do with chronic low back pain and citations of chronic pain guidelines are not applicable. Accordingly, the provided oxycodone-acetaminophen tablets were medically necessary for treatment of this patient.Final Result: The reviewer determined that the medication at issue was 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 sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for mastectomy, simple, complete, biopsy or excision of lymph node(s), open, deep axillary node(s), injection procedure, radioactive tracer for identification of sentinel node, and lymphatics and lymph nodes imaging. Based on the patients family history, workup, and genetic counseling, she is thought to have an increased risk of breast cancer. The patient has requested prophylactic bilateral simple mastectomy and lymph node sampling in order to reduce her risk for breast cancer. However, prophylactic bilateral mastectomy with lymph node sampling for risk reduction of breast cancer risk has only been demonstrated to be effective and medically necessary for individuals with documented inherited germline mutations (NCCN Guidelines for Genetic/Familial High-Risk Assessment: Breast, Ovarian, Pancreatic). The most well documented germline mutation of BRCA 1/2 that supports prophylactic surgery is wild-type for the patient and therefore not medically necessary for this patient. In addition to continued updated multi-panel germ-line testing, the patient has a number of dietary/lifestyle/and chemoprevention interventions that are available to her for risk reduction (NCCN Guidelines for Breast Cancer Risk Reduction). Under these circumstances, the requested mastectomy, simple, complete, biopsy or excision of lymph node(s), open, deep axillary node(s), injection procedure, radioactive tracer for identification of sentinel node, and lymphatics and lymph nodes imaging are not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in medical 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Doppler-guided transanal hemorrhoidal dearterialization for treatment of the enrollee who has a history of hemorrhoids. Findings:  2/3 of the physician reviewers found that THD is a technique used by colorectal surgeons as a treatment option for hemorrhoids. Multiple studies in support of THD have been recently published. For example, a recent systematic review and meta-analysis was published in 2015 by colleagues regarding the clinical outcomes and effectiveness of surgical treatments for hemorrhoids.  The review included 98 studies with 11 treatments for hemorrhoids and 7,827 patients.  The authors concluded that THD was associated with less postoperative bleeding and therefore, less emergency reoperations as well as decreased postoperative complications, shorter operative time, and decreased pain.  The authors concluded that the low cost of THD, low complication rate, shorter operating time and decreased levels of postoperative pain, but higher recurrence rate, may suggest THD as a safe, quick and easy initial surgical option.   In another study by colleagues, the authors concluded that THD is a safe and effective treatment of hemorrhoid disease. As such, the current medical evidence supports the efficacy of this treatment option for the treatment of hemorrhoids in patients who have exhausted conventional nonsurgical options. All told, Doppler-guided transanal hemorrhoidal dearterialization performed was likely to have been of greater benefit than other treatment modalities for the treatment of this patients hemorrhoidal disease. Final Result: 2/3 of the reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in surgery with sub-specialty certification in colon and rectal 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.Physician reviewer number two is board certified in surgery with sub-specialty certification in colon and rectal 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.Physician reviewer number three is board certified in surgery with sub-specialty certification in colon and rectal 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

A 52-year-old female  has requested coverage for intensity modulated radiation therapy (IMRT) and a multi-leaf collimator device for treatment of her ovarian cancer.  Findings:  Three physician reviewers found that the patient was diagnosed with serous borderline ovarian carcinoma eleven years ago. She did not receive any adjuvant chemotherapy or radiation therapy at that time. Within the past year, the patient underwent a surveillance chest x-ray, which showed a right paratracheal mass. A CT scan and biopsy was consistent with a metastatic carcinoma. Further metastatic workup was negative. A surgical resection of the mass was performed and the pathology reports indicated that a tumor was present at the anterior left posterior resection margin, as well as in the vascular space. Post-operative irradiation to the surgical bed was recommended. The patient is requesting authorization for intensity modulated radiation therapy (IMRT). The role of post-operative radiation to the surgical bed is reasonable in this patients case. The recommended dose of between 50 and 60 Gy, as outlined in the initial consultation by the radiation oncologist, is also reasonable in this patients case. However, there is no rationale provided as to why IMRT is needed in this case and there is no notation made as to why the use of a conventional 3D approach would be problematic. In this case, there is no evidence of a dosimetric plan demonstrating that certain dose constraints to normal surrounding tissue could not be met with conventional 3D radiation therapy. All told, there is inadequate data indicating that the use of IMRT would be more beneficial for this patient than 3D conformal radiation.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old female enrollee has requested an Oasis Neuromonics device for the treatment of her tinnitus. Findings:  Two physician reviewers found that tinnitus is a common condition and is associated with hearing loss of varying degrees, as well as certain medications. While many medical and surgical treatments have been developed and tried over the years, there is no consistently beneficial therapy. Tinnitus is an entirely subjective symptom, which means that there is no way to accurately quantify the degree of tinnitus that the patient suffers from other than their own description of the severity, and how it affects their quality of life. The vast majority of tinnitus sufferers learn to accommodate the symptom, while a much smaller number learn to cope with the help of tranquilizers or sleep aids. The Oasis Neuromonics device is one of many that are offered to the small number of patients who seek alternatives for treatment of their symptoms. The article supplied by the patient for this device is a small study of only 35 patients, many of whom noted relief with this device. At this time, sufficient medical studies do not exist to show that the device significantly improves outcomes better than standard alternatives.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested authorization and coverage for fluorouracil 5% cream for treatment of the enrollees verruca vulgaris. Findings:  The physician reviewer found that the records provided for review document that this patient has tried and failed therapy with liquid nitrogen as well as cantharone plus. However, the requested medication, fluorouracil 5% cream has not been U.S. Food and Drug Administration (FDA) approved for the treatment of verruca vulgaris in the pediatric population. Given that the patient is an eight-year-old, the requested fluorouracil 5% cream is not supported as medically necessary for treatment of recalcitrant verruca vulgaris. 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 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: Upheld

A 55-year-old female enrollee has requested gender reassignment procedure, bilateral mastectomy for treatment of her medical condition.  Findings:  The physician reviewer found that this patient has a significant psychiatric history of anorexia nervosa, schizoaffective disorder, and possible borderline personality disorder. She has been assessed with gender identity disorder and wishes to undergo bilateral mastectomy. The patients contention that she would be better served by bilateral mastectomy is negated by her variable compliance with much of her previous treatment. In light of the variable participation in PHP, the patient is unlikely to attend to her post-operative care as required by her provider. Further, given the patients ongoing struggle with anorexia nervosa and other psychiatric conditions, gender reassignment surgery is not clinically appropriate at this time. Considering the patients comorbid psychiatric illnesses, the requested bilateral mastectomy is not necessary for treatment of this patients medical condition at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee has requested neck surgery, brand name medications Percocet and Norco, and Carisoprodol and Diazepam 10 mg for treatment of his neck pain.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates the patient would not benefit from the continued use of Percocet, Norco, Carisoprodol, and Diazepam given the lack of any significant relief to warrant continued use, in addition to the presence of significant risk factors. In the medical literature, Savage and colleagues noted that, effective management of pain in patients with a co-occurring addictive disorder requires a comprehensive approach that recognizes the biological, pharmacological, social, and psychiatric aspect of substance misuse and addiction, as well as practical means to manage risk, treat pain effectively, and ensure patients safety. With regard to Carisoprodol, the FDA recommends its use for no longer than two to three weeks in order to avoid the risk of dependence, withdrawal, and abuse. The documentation suggests the patient has a history of non-compliance with medication use and inconsistent urine drug screens. The patient has previously stated he cannot take generic medications due to thyroid disease and side effects; however, the submitted medical records do not provide confirmatory evidence of this. Additionally, there are other more appropriate therapies available to provide short-term pain relief. All told, the medical necessity for continued use of brand name medications Percocet and Norco, as well as Carisoprodol, and Diazepam, is not demonstrated in the records provided for review. Regarding the request for neck surgery, this patient does have objective findings to substantiate complaints of pain, including cervical pathology warranting surgical intervention. An article by Haldeman and colleagues concluded that it is not clear from the evidence that long-term outcomes are improved with the surgical treatment of cervical radiculopathy compared with non-operative measures. However, relatively rapid and substantial relief of pain and impairment in the short term (6-12 weeks after surgery) after surgical treatment appears to have been reliably achieved. This patient is noted to have evidence of myelopathy at C2-3. As such, anterior cervical discectomy and fusion (ACDF) at C2-3 may be beneficial. However, the patient is considered a poor surgical candidate at this time in the absence of a primary care provider in place for medication management. The Health Plans recommendation of participation in a chemical dependency evaluation is medically reasonable and appropriate. This should occur within a chronic pain management program. The patient should be re-evaluated in three months to determine if he is an appropriate candidate for surgical intervention at that time.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:The parent of an enrollee has requested authorization and coverage for clinical/whole exome sequencing (WES) for evaluation of the enrollees alopecia universalis.  Findings:  Two physician reviewers found that WES has been endorsed by the American College of Medical Genetics and Genomics, which states that WES should be considered in the clinical diagnostic assessment of a phenotypically affected individual when: The phenotype or family history data strongly implicate a genetic etiology, but the phenotype does not correspond with a specific disorder for which a genetic test targeting a specific gene is available on a clinical basis; a patient presents with a defined genetic disorder that demonstrates a high degree of genetic heterogeneity, making WES or WGS analysis of multiple genes simultaneously a more practical approach; A patient presents with a likely genetic disorder but specific genetic tests available for that phenotype have failed to arrive at a diagnosis. Based on the clinical documentation submitted for review, the patient meets these criteria. In this case, the proposed testing is supported by the strong genetic underpinnings of alopecia areata, the polygenic nature of the condition, the presence of clinically relevant conditions that can present with alopecia areata, and that WES is clinically useful and has evidence based support in the peer-reviewed literature. Final Result: The reviewers determined that the requested testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in pediatrics and clinical genetics 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 40-year-old female enrollee has requested for revision of bariatric surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that the long-term outcome of gastric bypass offers only a 55% excess body weight loss at best. Therefore, some patients will have inadequate weight loss, or even weight regain, without having any anatomical explanation for it.
Appeal type: Experimental/Investigational
Decision: Overturned

The father of a 17-year-old female enrollee requested authorization and coverage of Rituxan. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees Evans syndrome/thrombocytopenia.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Because two of the three  physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old male enrollee has requested authorization and coverage for gamma knife stereotactic radiation treatment for treatment of the enrollees metastatic renal cell carcinoma to the brain. Findings:  The physician reviewer found that at issue is the use of SRS for multiple brain metastases (>4). In this patients case, the interpretation of the MRI by the radiation oncologist offering SRS is that there are 3 lesions, plus 3 untreated lesions, while other physicians document greater than 12 lesions.  Stereotactic radiosurgery (SRS) implies the use of technologies which improve targeting accuracy, and allow for high dose, single fraction, radiation delivery. Cranial SRS is a radiation planning and delivery technique in which radiation is targeted to discrete lesions to allow for ablative doses of radiation to be delivered. Generally, chemotherapy does not penetrate the blood brain barrier, and therefore radiation is the only viable option for patients with multiple brain metastases.  Whole brain radiation is the standard treatment for patients with greater than 4 brain metastases.  For patients with 1, 2, 3, or 4 brain metastases, multiple cooperative group randomized controlled studies have shown no survival benefit with the addition of whole brain radiation to stereotactic radiosurgery.  Several studies have described SRS for multiple brain metastases.  A study by Liew and colleagues found that a larger number of lesions was associated with poorer survival, but did not impact tumor control and the authors recommend SRS +/- whole brain radiation for individuals with more than eight metastases. Another study indicated that the number of metastases was not significant in a multivariate analysis of survival (Powell, et al.).  A study examining patients with four or more brain metastases concluded that because total treatment volume was the most significant predictor of survival, the total volume of brain metastases, rather than the number of metastases, should be considered in identifying appropriate radiosurgery candidates. They did not evaluate the impact of omitting whole brain radiation (Bhatnager, et al.).  Although several studies have reported on the use of SRS for patients with multiple brain metastases, many of the studies did not study SRS versus treatment with whole brain radiation, but rather in conjunction with or independent of whole brain radiation therapy. SRS is not currently considered a standard therapy and remains investigational, particularly when omitting whole brain radiation. Therefore, the requested gamma knife stereotactic radiation treatment is not medically necessary for treatment of the patients medical condition. The Health Plans denial was appropriate and should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested mid-wife services for home birth treatment of her medical condition.  Findings: The physician reviewer found that the American College of Obstetricians and Gynecologists (ACOG) states that hospitals and birthing centers are the safest setting for birth. ACOG notes in its Committee Opinion Number 476 that although the absolute risk of planned home birth is low, published medical evidence shows it does carry a two to three fold increase in the risk of newborn death compared to planned hospital births. While ACOG does not support planned home births at this time, it states that it is especially important for women who decide to deliver at home be low risk. In this case, the patient has a medical condition where maternal platelets are low. This may put the mother at risk for increased bleeding at the time of delivery. In addition, this medical condition has been associated with bleeding complications in the newborn. With this diagnosis, the patient is considered high risk and does not meet the recommended criteria of being low risk. In conclusion, this patient is considered a high risk patient who should delivery in a hospital setting where there is appropriate support to deal with any complications that may arise at delivery.  All told, 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 physician reviewer is board certified in obstetrics and gynecology 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.