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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for balloon ostial dilation for treatment of the enrollee's nasal congestion and sinus pressure.Findings:  All three physician reviewers found that while sinus ostial dilation, even by balloon sinuplasty, is an appropriate therapeutic option for patients with chronic sinusitis, the criteria for this patient has not been met. The indication for balloon sinuplasty (balloon ostial dilation) is chronic sinusitis refractory to maximal medical treatment. The American Academy of Otolaryngology Head and Neck Surgery defines chronic rhinosinusitis (CRS) as a clinical disorder characterized by inflammation of the mucosa of the nose and paranasal sinuses with associated signs and symptoms of 12 weeks consecutive duration. CRS is characterized by two or more symptoms, one of which is nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip), with or without facial pain/pressure and reduction or loss of smell with endoscopic evidence of mucopurulence, edema, and/or polyps and/or CT presence of mucosal thickening or air fluid levels in the sinuses. Chronic rhinosinusitis was not documented in this patient. While there was a notation of recurrent sinus infections, there was no documentation of 12 weeks of consecutive disease. However, recurrent sinusitis is not an indication for balloon sinuplasty. There was no documentation of chronology of disease, symptoms or treatment. There was no documentation of findings on nasal endoscopy suggestive of sinus disease. For these reasons noted above, balloon ostial dilation is not likely more effective than the standard therapies available for treatment of this patients medical condition.  Final Result: Three physician 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: All three physician reviewers are board certified in otolaryngology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for percutaneous tibial nerve stimulation. The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollee who has a history of overactive bladder. Percutaneous tibial nerve stimulation (PTNS) as third-line therapy after failed physical therapy, medications and behavior modification has been clearly shown to have a benefit paralleling that of medical management and is recommended as a therapeutic intervention prior to more invasive techniques. The evidence suggests benefit in patients who have failed behavioral and/or medication therapies. Even in the context of post-surgical therapies, as is the case with this patient, PTNS has shown benefit if the other therapies have failed. The European Urological Association indicates PTNS has a Grade B recommendation, which is sufficient to support its use in this clinical setting. In sum, PTNS is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found the requested percutaneous tibial nerve stimulation is not 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 requested services 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:  All three reviewers are board certified in urology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the molecular pathology testing by Redpath Integrated Pathology, Inc. for evaluation of the enrollees pancreatic cyst. Findings: The physician reviewers found there is sufficient support for the services at issue in this patients case. She had a mucinous pancreatic cyst which puts her at risk for possible malignancy. The standard of care is to test the fluid from the cyst for KRAS and GNAS as part of the diagnostic work-up to guide the need for surgical excision. In sum, molecular pathology testing by Redpath Integrated Pathology, Inc. was likely to be of greater benefit than other modalities for evaluating this patient.Final Result: 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: All three physician reviewers 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: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee requested authorization and coverage of biofeedback therapy. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees urinary incontinence. Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician 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 physician 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: Upheld

A 54-year-old female enrollee has requested an MRI of the left knee for an evaluation of her osteoarthritis. Findings:  The physician reviewer found that in the peer-reviewed literature there is a lack of support for the use of MRI of the knee in the evaluation of advanced osteoarthritis. The American College of Radiology guidelines do not recommend MRI in patients with documented advanced osteoarthritis on plain radiographs. MRI is sometimes utilized in patients with advanced osteoarthritis for preoperative planning. In patients with advanced osteoarthritis, MRI does not add any further clinical information. MRI of the left knee is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 21-year-old female enrollee has requested partial hospitalization program (PHP) services for treatment of her eating disorder.  Findings:  The physician reviewer found that this patient presents a picture of eating disorder treatment that has been very fragmented, poorly coordinated, and extremely frustrating for this patient to navigate. These are all factors that would reasonably be expected to markedly impede the patients chances of achieving a meaningful recovery in the least amount of time. The progress note on the date specified indicates that this patient has already started to relapse into her restricting cycle since discharge from PHP treatment. In addition, her symptoms of depression and frustration seem to have precipitated her first panic attack. Her note prior to discharge seems to indicate that she was still preoccupied with intrusive, repetitive thoughts about her eating disorder. She also requires some structure to gain weight. Applying the American Psychiatric Association (APA) guidelines, this patient meets the criteria for PHP level of care. Therefore, the requested PHP services are supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old male enrollee requested authorization and coverage of continued residential treatment services. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees behavioral health problems.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.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested intensity modulated radiation for treatment of the enrollees prostate cancer.  Findings: Three physician reviewers found that the current guidelines do not support the routine use of IMRT in the treatment of bone metastases.  IMRT uses dose painting and reduced treatment planning margins to create steep dose gradients adjacent to critical normal structures.  This level of complex planning is not necessary in the treatment of standard spine metastases.  Standard therapy for patients with spine metastases is with three-dimensional conformal techniques. There is a lack of data suggesting that treatment of these patients with IMRT results in decreased toxicity or improved local control compared to standard therapy with photon techniques.  Furthermore, the records do not document a clinical reason which would preclude the use of a standard three-dimensional technique using photons.  Thus, IMRT was not likely to have been of greater benefit than other treatment options.Final Result: Three reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three physician reviewers are board certified in radiation 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: At issue is whether the FoundationOne genetic testing that was provided was likely to have been more beneficial for the evaluation of the patients condition than any available standard therapy. The enrollee had a history of breast cancer treated with radiation therapy and chemotherapy found to have recurrent and metastatic breast cancer. One out of three physician reviewers found that FoundationOne testing provides a rational basis for the choice of available standard therapies or available clinical trials. Studies of genetic testing demonstrate improved clinical outcomes. This patient has already demonstrated significant chemoresistance and progression following first-line chemotherapy choices. Her metastatic recurrence is being treated empirically with combination endocrine therapy of palbociclib/letrozole as an appropriate first-line therapy. The patient will likely need additional therapeutic options after progression on this first-line regimen.  Therefore, the FoundationOne genetic testing that was provided was likely to have been more beneficial for the evaluation of the patients condition than any available standard therapy. Two out of three physician reviewers found that there is a lack of data to show that this information can guide treatment decisions for patients with metastatic breast cancer. The use of FoundationOne testing, continues to be the subject of ongoing clinical trials. As such, the FoundationOne genetic testing provided was not likely to have been more beneficial for the evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested test 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: 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for epidural steroid injection at L5-S1. Helm Ii and colleagues report that transforaminal epidural steroid injections may provide significant benefits for patients with radiculopathy. In this case despite the presence of a diagnosis of lumbar radiculopathy, the records do not document objective evidence of active radiculopathy, noted no benefit from prior epidural steroid injections, and did not provide a rationale for a repeat injection in the face of limited previous benefit. Therefore, an epidural steroid injection at L5-S1 is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for rifaximin 550 mg, one tablet three times a day for 14 days. The records provided for review document that this patient has a diagnosis of bacterial overgrowth in the setting of inflammatory bowel disease, diarrhea predominant (IBS-D). Rifaximin has been demonstrated to be safe and effective for the treatment of IBS-D and this medication is U.S. Food and Drug Administration (FDA) approved for this indication (Schoenfeld, et al.). In the TARGET-3 trial of over 1,000 patients, rifaximin proved effective with significant symptom improvement in IBS-D (Lembo, et al.). Additionally, rifaximin has data demonstrating its efficacy in the treatment of small intestinal bacterial overgrowth (SIBO) (Gatta, et al.). The FDA-approved dosage for IBS-D based on clinical studies is 550 mg three times daily for 14 days. Per the FDA approval, the medication can be used for two similar courses 10 weeks apart. However, this patients records do not include documentation of recurrent symptoms after a 10-week interval since completion of the prior rifaximin dose. Therefore, the requested rifaximin 550 mg, one tablet three times a day for 14 days is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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

This patient is a 47-year-old male with a history of methamphetamine abuse, depression and suicide attempts. He is hepatitis C, and HIV positive. The patient had a nine-month span of sobriety in 1999 and was again sober from June 2005 through February 2006. The patient was hospitalized for three weeks for detoxification and depression from May 2006 through June 2006. He had used intravenous (IV) methamphetamine three to four times per week before that admission. The patient was admitted to the residential care facility on the day following his hospital discharge. The record indicates he had refused sober living placement and outpatient treatment and had threatened to harm himself if not treated at a residential center. He was reportedly homeless at the time of his admission.The patient has requested reimbursement for the residential treatment services provided from June 2006 through July 2006.  The Health Plan denied the request based upon a determination that these services were not medically necessary.The documentation submitted does not demonstrate that the patient required residential treatment. Although he did have a long-standing history of methamphetamine abuse, he had been successfully detoxified prior to this admission and did not demonstrate physical symptoms of withdrawal. The patient had threatened to harm himself if he was not admitted to a residential treatment facility, however this type of manipulation does not indicate the patient was actively suicidal. There were no symptoms of homicidal ideation or active psychosis and he was medically stable at the time of admission. The patient did not require 24-hour residential care and could have continued his recovery through a partial hospitalization or intensive outpatient program. Therefore, I have determined that the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for massage therapy. The enrollee has chronic, midline low back pain and right-sided sciatica. The enrollee has tried physical therapy without improvement. He would like to avoid medications, if possible. The enrollee was referred to chiropractic care for massage therapy and acupuncture treatment. Studies are limited regarding the effectiveness of massage for treating lower back pain. The few studies available show that massage is as effective as placebo, and not as effective as electrical stimulation for treating chronic low back pain. Final Result: Two of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified chiropractors 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: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee requested authorization and coverage of the medication Nexium. The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollees gastroesophageal reflux disease.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old female enrollee has requested three Orthovisc (hyaluronan) injections for treatment of her right knee pain.Findings:  The physician reviewer found that viscosupplementation for the treatment of osteoarthritis of the knee has been shown to be effective, and it is most suitable for patients with mild to moderate disease. It has been shown to be safe, with local transient knee pain or swelling without long-term sequelae as the usual adverse events. Significant improvement in pain and functional outcomes are reported, and there is some laboratory evidence of a beneficial long-term effect on arthritis progression.In this patients case, her prior surgery and her clinical picture point to early degenerative disease as the proper diagnosis. The utilization of viscosupplementation is an appropriate treatment for this diagnosis, and therefore, should be covered by the Health Plan.
Appeal type: Medical Necessity
Decision: Overturned

A 36-year-old male enrollee has requested authorization and coverage for Lyrica.  The Health Plan has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees pain.  Findings:  Three physician reviewers found that the patient has a history of multiple back surgeries. He is status post lumbar fusion.  He now has recurrent pain.  Neurontin, Vicodin and oral steroids have not resulted in pain relief.  The patient has requested coverage for Lyrica.  The Health Plan has denied this request.  Per the Health Plan, Lyrica is investigational for the treatment of this patient.  The patient is appealing this denial.  The use of Lyrica is exceedingly common for neuropathies of all etiologies.  Lyrica is a first-line agent in the treatment of refractory neuropathy along with gabapentin and tricyclic antidepressants.  This patient has failed to obtain relief on Neurontin.  In this patients case, two surgical corrections have been attempted, and the patient has not responded to gabapentin, NSAIDs, low-dose narcotics, or steroids. The alternatives to Lyrica include interventional procedures, spinal cord stimulation, re-operation or higher dose narcotics, all of which involve a higher likelihood of morbidity.  The patient has done well with low-dose Lyrica, with little to no adverse effects.  Therefore, in this clinical situation, Lyrica is likely to be more effective than other treatment modalities.