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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Xifaxan 200 mg tablet three (3) times a day for 14 days. The U.S. Food and Drug Administration (FDA) approves the use of Xifaxan (generic name rifaximin) for the treatment of irritable bowel syndrome with diarrhea. In a study of 50 children with irritable bowel syndrome (IBS), Scarpellini and colleagues found that rifaximin was effective and safe in treating small intestinal bacterial overgrowth (SIBO) treatment and IBS symptoms in children. In this case, the patient has tried and failed multiple treatments, including metronidazole. Given that the patient continues to have persistent abdominal pain, the requested medication is medically indicated. Therefore, Xifaxan 200 mg tablet three (3) times a day for 14 days are medically necessary for the treatment of this patient.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 pediatrics with sub-specialty certification in pediatric 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcatheter permanent occlusion or embolization, with flow diversion.Findings:  Three physician reviewers found that there is support for the requested services in this patients case. In the medical literature, 44 small (less than 10 mm) aneurysms of the internal carotid artery were treated with flow diversion. There was one major complication of intraprocedural rupture. The authors concluded that flow diversion is a safe treatment alternative for small internal carotid artery aneurysms. In an additional study, the safety and efficacy of flow diversion treatment for 100 consecutive patients with small (less than or equal to 7 mm) aneurysms was reported. The authors concluded that this treatment is associated with low complication rates and high aneurysm occlusion rates and is a safe and effective alternative to conventional endovascular techniques for small aneurysms. Based on the available literature, flow diversion is an effective technique for treating small aneurysms of the internal carotid artery. It may offer a decreased risk of intraoperative rupture as the aneurysm sac itself does not have to be catheterized during the procedure, particularly for small aneurysms which appear to be at increased risk of rupture during coiling compared to larger aneurysms. In this case, the patients provider is planning to treat both small aneurysms with a single flow diverting device. Deployment of a single flow diverting device is likely to be safer than catheterizing and coiling two different small aneurysms. In sum, transcatheter permanent occlusion or embolization, with flow diversion is likely to be superior over other treatment options. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in neurological 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc (or equivalent) viscosupplementation knee injections for treatment of the enrollees bilateral knee osteoarthritis. Findings:  The physician reviewer found that there is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Researchers conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested for Taxotere chemotherapy for treatment of her adenocarcinoma of the lung. Findings:  The physician reviewer found that Alimta has recently gained accelerated approval from the FDA based on randomized trials in which it showed equivalent survival when combined with cisplatin (cddp) compared to gemcitabine/cisplatin. In this study, there was a striking advantage to the Alimta/cddp regimen for those patients with non-squamous histology like adenocarcinoma. In the second study cited in the FDA label, Alimta was tested in the maintenance setting versus placebo and again it showed a survival benefit which was most pronounced for adenocarcinoma and non-squamous histology in general, as noted by Ciuleanu and colleagues. A more recent phase II study looked at 50 patients with stage IIIB/IV adenocarcinoma with Alimta/Avastin/carboplatin followed by maintenance Avastin/Alimta. The study was not randomized, but the overall survival times were impressive.  There is no evidence suggesting that Taxotere is likely to have similar results.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old male enrollee has requested aquatic physical therapy for treatment of his tendonitis, rotator cuff syndrome, and herniation of lumbar intervertebral disc.  Findings:  The physician reviewer found that swimming and aquatically based exercise can be beneficial for overall health for almost everyone (Becker, et al). Aquatic exercise may be helpful in conditions such as low back pain or joint pains, but the role of formal aquatic therapy is not established (Waller, et al.). Formal aquatic therapy is medically necessary only for patients in specific circumstances such as for patients who require therapy in a partially body weight unloaded environment given significant weight-bearing restrictions or profound neurological weakness. An example of an appropriate rationale for formal aquatic therapy is a patient who requires significant body weight unloading of both lower limbs due to major lower limb surgeries. As such, this patient does not have a condition for which formal aquatic therapy is medically necessary. Specifically, he does not have weight-bearing restrictions or weakness in the limbs to the degree that he cannot participate in land-based therapy or exercise. While participation in some exercise is generally encouraged in the setting of chronic pain conditions and swimming or aquatic exercise are good options, there is no specific circumstance in the present case supporting the need of formal aquatic therapy. Water aerobics, swimming or pool walking can be pursued independently however these therapies are not clinically necessary for the patient to obtain functional improvement. Overall, no marginally significant benefit with respect to the patients health or functional outcomes would be expected with the requested formal aquatic therapy over ongoing independent exercise performed on land or in water. For these reasons, the aquatic therapy at issue is not medically necessary for management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-month-old male enrollee has requested Elidel 1% cream for the treatment of the enrollees atopic dermatitis. Findings:  The physician reviewer found that records indicate that this young patient with documented atopic dermatitis, food and inhalant allergies and asthma has experienced inadequate response to the standard therapies provided for his significant atopic dermatitis.  These include topical steroids. Standard medical care for atopic dermatitis is to induce a remission with topical steroids, but to limit their use to avoid systemic absorption. If the skin is widely involved, as in this patient, too much steroid is absorbed. It is especially important to infants to avoid systemic absorption of steroids. Elidel is medically necessary and more clinically appropriate for inducing and maintaining remission of atopic dermatitis in this patient as a steroid-sparing therapy.  The use of Elidel for treatment of atopic dermatitis in infants and children is the standard of care in the medical community at this time.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for Januvia 100 mg tablets once daily. Januvia (sitagliptin) is a member of a family of medications known as dipeptidyl peptidase 4 (DPP-4) inhibitors. These medications stimulate insulin secretion and reduce glucagon secretion in a glucose-dependent manner, both effects contributing to the glucose-lowering activity. This medication typically reduces the hemoglobin Alc level by about 0.60.8%. Januvia is a safe and well-tolerated medication for patients with type 2 diabetes. The current medical evidence supports the requested medication in this clinical setting. Therefore, Januvia 100 mg tablets once daily are medically necessary for the treatment of this patient. 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-UM for their condition of choroidal melanoma. Findings:  The physician reviewer found that An enrollee has requested reimbursement for the DecisionDx-UM. Findings:  Three physician reviewers found cytogenetic testing of choroidal melanoma has been an established method of laboratory evaluation of melanomas for 10 years. The medical literature supports the routine use of this testing for patients with uveal melanoma. The current standard of care is to adjust a patients monitoring and surveillance based on the genetic profile of the tumor. Patient counseling and eligibility for clinical treatment trials are based heavily on the tumor genetic profile. The current medical evidence supports the testing at issue in this clinical setting. Therefore, DecisionDx-UM (CPT 84999) was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the testing at issue was 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 reviewers 1, 2 and 3 are board certified in ophthalmology 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 49-year-old female enrollee requested authorization and coverage of Mohs surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees back lesion.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for an additional 10 hours per week of ABA therapy (30 hours per week total). Based on the presenting information, ABA treatment guidelines developed by the Council of Autism Service Providers (CASP) and the ABA Coding Coalition, and the medical necessity criteria by Papatola and Lustig, an additional 10 hours per week of ABA therapy (30 hours per week total) are not medically necessary for treatment of this patient. The CASP and the ABA Coding Coalition both highlight the required components of ABA service provision. This includes assessment, goal setting, supervision, service intensity, and discharge elements. The ABA Coding Coalition indicates that treatment recommendations are based on a comprehensive assessment to develop an individualized treatment plan based on the patients direct observable data. Further, the CASP specifies that, Treatment may vary in terms of intensity and duration, the complexity and range of treatment goals, and the extent of direct treatment provided. Many variables, including the number, complexity, and intensity of behavioral targets and the clients own response to treatment help determine which model is most appropriate. Given this patients multiple authorization requests, the number of goals being addressed during treatment, and the patients positive response to treatment, the dosage of 20 hours recommended by the provider is appropriate. While the parent has requested a higher dosage, there is a lack of supporting documentation that demonstrates that the higher dosage is medically necessary. In addition, an additional 10 hours per week of ABA therapy (30 hours per week total) does not meet the medical necessity criteria outlined by Papatola and Lustig. The records document that the patient has made more progress with 20 hours in the previous authorization than at 30 hours during the initial authorization. Moreover, an additional 10 hours per week of ABA therapy (30 hours per week total) is not in accordance with the generally accepted standards of mental health and substance use disorder care or clinically appropriate in terms of frequency, extent, and duration. For these reasons, an additional 10 hours per week of ABA therapy (30 hours per week total) are not medically necessary for treatment of this patient. 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 a licensed B.C.B.A, board certified in psychology 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: An enrollee has requested authorization and coverage for Vemlidy, 25 mg daily. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis B.Findings: Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Diseases (AASLD) recommend entecavir and tenofovir compared to alternatives for the treatment of chronic hepatitis B (Terrault, et al). In comparison with tenofovir disoproxil fumarate (Viread), the Vemlidy formulation of tenofovir is effective for treatment of hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. As such, the request to switch the patient to Vemlidy to reduce the risk of tenofovir-related nephrotoxicity and loss of bone density is medically reasonable and appropriate. For these reasons, Vemlidy 25 mg daily is medically necessary for the treatment of this patients hepatitis B. 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 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 54-year-old female enrollee has requested a continuous glucose monitoring system and related supplies for the treatment of her type I diabetes mellitus. Findings:  The physician reviewer found that there is evidence in the literature about the benefits of CGMS in adults and children and the device is accepted in the medical community that specializes in management of diabetes. This years American Diabetes Association's 2008 Standards of Medical Care in Diabetes states that, `continuous glucose monitoring may be a supplemental tool to SMBG (self monitoring blood glucose) for selected patients with type 1 diabetes, especially those with hypoglycemia unawareness.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. In this clinical setting, the use of the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Final Result: Three 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 diagnostic radiology 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.that
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Botox 200 mg every 12 weeks. In 2016, the American Academy of Neurology (AAN) updated its guidelines to support the use of Botox for the management of chronic migraine, defined as attacks lasting four or more hours on at least 15 days each month for three months. A 2018 review of the current evidence of Botox in the prevention of chronic migraine by Frampton and Silberstein reported that the available data has demonstrated that Botox is an effective and generally well-tolerated option for the prevention of chronic migraines. The authors found that Botox may be particularly useful for patients who have previously failed to respond to or are intolerant of commonly prescribed oral prophylactics. In this case, the patient has history of chronic migraines that has not adequately responded to oral preventative medications. The use of Botox for this patient has been effective in increasing the number of headache-free days and improved quality of life. The combination of Botulinum toxin and Ajovy has further increased the number of headache-free days and extended the efficacy of Botox therapy. All told, the requested Botox 200 mg every 12 weeks is medically necessary for treatment of this patient. 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 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 a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma molecular profiling gene test. Based on the patients American Joint Committee on Cancer (AJCC) clinical stage, she has a five-year and 10-year melanoma survival rates of 99% and 98%, respectively (Gershenwald, et al.). The DecisionDx-Melanoma molecular profiling test was performed and yielded a Class 1A score, consistent with the lowest risk of recurrence within five years. Based on the gene expression profiling score alone, the patients five-year melanoma specific survival is as high as 100%, signifying a relatively equivalent prognosis for the patient. Currently, there is a paucity of peer-reviewed medical literature demonstrating improved patient health outcomes with use of the DecisionDx-Melanoma assay when compared to standard risk profiling. In the absence of data obtained from prospective randomized controlled trials showing some measurable clinical benefit, the National Comprehensive Cancer Network (NCCN) does not recommend the DecisionDx-Melanoma for routine use. Thus, the DecisionDx-Melanoma molecular profiling gene test provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the DecisionDx-Melanoma molecular profiling gene test provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in dermatology 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.