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

A 33-year-old female enrollee requested authorization and coverage of continued intravenous antibiotic for the treatment of lyme disease.  The health plan denied the enrollees request indicating that long-term antibiotic treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested long-term antibiotic treatment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old male enrollee has requested heart transplantation and 6 minute walking test for treatment of his chronic systolic heart failure.  Findings:  The physician reviewer found the medical literature includes evidence supporting heart transplantation in patients with sarcoidosis. Zaidi and colleagues followed 65 patients with sarcoidosis and reported that at one year post transplant, survival was significantly better for the sarcoidosis patients compared to all other patients. The authors concluded that the diagnosis of sarcoid tumor should not disqualify potential transplant candidates. Milman and colleagues reported four consecutive cases of cardiac sarcoidosis undergoing heart transplant and concluded that transplantation is a viable treatment for patients with cardiac sarcoidosis. The patient did respond to steroid therapy with noted improvement of the sarcoidosis nodules. Given the available data demonstrating improved health outcomes in patients with sarcoidosis, the requested heart transplantation and 6 minute walking test are supported as medically necessary for treatment of this patients dilated ischemic cardiomyopathy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: At issue is whether Cardio IQ panel tests that were rendered were likely to have been more beneficial for the evaluation of the patients medical condition than any available standard therapy. The records documented a diagnosis of dyslipidemia which was treated successfully with medication therapy when taken as ordered.Findings:  Three physician reviewers found that the tests at issue were not likely to have provided additional information that would have affected treatment decisions for this patient. She had known dyslipidemia. There are multiple prior evaluations of both standard and advanced lipid profiles. In this case, this had been determined previously, and the risk was high enough to start medical treatment. Repeated measurements of advanced lipid profile parameters are not currently recommended or indicated. There is no guideline directed goals of therapy for these advanced lipid measurements beyond the standard LDL cholesterol parameters in the published 2018 American College of Cardiology/American Heart Association (ACC/AHA) guidelines.  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 subspecialty certification in cardiovascular disease 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: An enrollee has requested authorization and coverage for Euflexxa injections. Findings:  Two of the three physician reviewers found the records note the diagnosis of left knee osteoarthritis. It is unclear how this diagnosis has been made, as there are no imaging reports or operative reports in the submitted records which document the presence of left knee osteoarthritis.  He has been managed with an appropriate course of conservative management and has received viscosupplementation treatments with reported good response lasting four to five months. There is no documentation of a failed trial of corticosteroid injections.  Repeat series of injections are recommended by most guidelines only if there is documented significant improvement in symptoms for six months or more, and symptoms recur. This is not supported by the documentation. Therefore, Euflexxa injections are not likely to be more effective than other treatment options.Final Result: The reviewers determined that the requested medication is 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: 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: Overturned

An enrollee has requested authorization and coverage for bilateral Euflexxa injections. This patient has been diagnosed with osteoarthritis of both knees. Her provider has recommended weight reduction prior to proceeding with total knee arthroplasties. Intra-articular corticosteroid injections were tried, but she only obtained temporary relief for one month. The provider has deemed her to be an appropriate candidate for viscosupplementation while trying to postpone the total knee arthroplasties. An exhaustive review of the current medical literature pertaining to the viscosupplementation reveals mixed results. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited. 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 the options are limited. In this case, the options are limited, with need for temporary pain relief while weight reduction is being attempted prior to the total knee arthroplasties. The medical evidence supports the requested services in this setting. Therefore, the requested bilateral Euflexxa injections are medically necessary for the treatment of this patient. 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:An enrollee has requested authorization and coverage for the Medtronic Minimed 630G insulin pump for evaluation of adrenal insufficiency. Findings:  The physician reviewer found that The records document that this patient has remained symptomatic despite treatment with hydrocortisone in divided doses. Delivery of subcutaneous hydrocortisone has been recommended in an attempt to mimic the patients natural circadian rhythm. However, there is a paucity of controlled or peer-reviewed studies to indicate that the insulin pump is able to effectively deliver hydrocortisone for the treatment of adrenal insufficiency. The most recent guidelines from the Endocrine Society do not include use of a hydrocortisone infusion pump for the management of adrenal insufficiency. Patients that do not respond to short acting hydrocortisone may be treated with prednisone, prednisolone or dexamethasone in one or two doses. In addition, the Medtronic 630G insulin pump has been approved by the U.S. Food and Drug Administration (FDA) for the subcutaneous delivery of short acting insulin of patients with diabetes mellitus. In this case, there is no documentation that the patient has diabetes mellitus or has been treated with the other available glucocorticoid preparations including prednisone or dexamethasone. Based on the information available and review of the current peer-reviewed medical literature, the requested Medtronic Minimed 630G insulin pump is not likely to be more beneficial for treatment of the patients adrenal insufficiency than any available standard therapy. Final Result: The reviewers determined that the te requested Medtronic Minimed 630G insulin pump is not likely to be more beneficial for treatment of the patients adrenal insufficiency than any available standard therapy. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 38-year-old male enrollee has requested remote real-time cardiac monitoring for evaluation of his tachycardia. Findings:  Two physician reviewers found that at this time, real-time cardiac monitoring has not been subjected to rigorous medical outcomes analysis. There is a lack of studies that definitely demonstrate this technologys superiority to standard loop monitoring or event monitoring. In this clinical situation, standard loop or event monitoring would have been the appropriate diagnostic test. Overall, the superior efficacy of real-time event monitoring has not been established.  Thus, real-time cardiac monitoring was not likely to have been the most efficacious method of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 10-year-old female enrollee has requested doxycycline injections for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The records indicate that a biopsy confirmed pathology consistent with a giant cell reparative granuloma/aneurysmal bone cyst.  The patient has been treated with extensive cortisone injections.  However, the mass has continued to grow in size.  There is a lack of support for the requested services in this clinical setting.  Per the current medical evidence, doxycycline is not generally accepted as a standard treatment in this clinical setting.  Additionally, as the patients tumor is noted to be growing rapidly, continued conservative treatment is not indicated. As such, the requested doxycycline injections for treatment of giant cell reparative granuloma with aneurysmal bone cyst characteristics are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 39-year-old female who is currently without breast cancer, but has a strong family history for this disease. The patients mother at age 38, one maternal aunt at age 50, and one maternal great aunt were diagnosed with breast cancer and subsequently died of the disease. In addition, the patient has two other maternal aunts diagnosed with DCIS in their seventies. The patient has requested authorization and coverage for BRCA 1 and BRCA 2 genetic testing. The Health Plan has determined the requested genetic testing is not medically necessary.The issue here is the medical necessity of BRCA 1 and BRCA 2 genetic testing in this patient with a strong family history of cancer. Although the patients geneticist indicates the probable risk of the patient having this mutant gene is 6%, circumstances (i.e., the death of all of those family members of their malignant disease) mitigate the ASCO recommendation of 10% risk cut-off for testing. Furthermore, BRCA testing is medically appropriate in women with two or more affected first- or second-degree relatives on the same side of family. Therefore, the patient meets medically necessity criteria for BRCA testing, and coverage for such testing should be provided. Accordingly, I have determined that the requested genetic testing is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee has requested Celebrex 200 mg, two tablets twice per day for treatment of her osteoarthritis. Findings:  The physician reviewer found that Celebrex is a selective COX-2 inhibitor indicated in the treatment of osteoarthritis, rheumatoid arthritis and familial adenomatous polyposis at doses of 200, 400 and 800 mg/day respectively. The requested dose of 800 mg per day of Celebrex exceeds the dosage recommended by the Food and Drug for treatment of osteoarthritis. The risk of cardiovascular events appears to increase with higher doses. In addition, there have been reports of gastric ulcers in patients being treated for osteoarthritis in doses higher than the FDA recommended daily dose. Moreover, the analgesic effects of higher doses of Celebrex were not shown to be better in a population of patients with ankylosing spondylitis. In sum, there are no studies that support the safety and efficacy of a dose of Celebrex of 800 mg/day for the treatment of osteoarthritis.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eight-year-old female has requested speech therapy for treatment of her autism.  Findings:  The physician reviewer found that in addition to being in the 3rd percentile for both receptive and comprehensive language, this patient carries multiple additional diagnoses including autism/pervasive developmental disorder and attention deficit/hyperactivity syndrome. Intellectually, however, based on the Woodcock-Johnson III test the patient is probably of normal or near-normal intellect.  Despite her normal capacity to learn, she remains in the 3rd percentile for language. This implies that she has not benefitted from the school-based group language instruction she has been receiving since the age of three. This may be related to her inattention and hyperactivity, which becomes most dysfunctional in a large group compared with an individual setting. The current group sessions have been inadequate for her to progress and develop language. The patient requires more intensive and individual speech therapy to develop any significant gains in language acquisition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old female enrollee has requested a toe dorsiflexion Dynasplint for treatment of her medical condition, which is status post cheilectomy.  Findings:  Three physician reviewers found that treatment for hallux limitus or hallux rigidus in the medical literature includes options such as footwear modifications, non-steroidals or surgery.  There is a lack of published high-grade medical literature supporting the efficacy of dynamic splinting using devices such as the Dynasplint in the setting of hallux limitus or hallux rigidus, whether preoperatively or postoperatively.  In the present case, the submitted records do not indicate that a sufficiently rigorous program of self-directed range of motion exercise had been utilized prior to application of the Dynasplint.  Moreover, there is no documentation of significant range of motion or other clinical benefit with any intervention in the present case.  In this patients case, the toe dorsiflexion Dynasplint was not likely to be superior over other treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested Marinol for medical treatment of her fibromyalgia.  Findings:  The physician reviewer found that the medical literature does not support Marinol for the treatment of this patients condition.  Wang and colleagues performed a systematic review of the medical literature in regards to the therapeutic use of cannabis and cannabis-based medicines.  The authors concluded that the risks associated with long-term use were poorly characterized in published clinical trials and observations studies.  All told, Marinol is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested for Byetta, 10 mcg subcutaneous pen for treatment of her diabetes.  Findings:  The physician reviewer found that consistent with the medical literature, Byetta is considered medically necessary when a patient has failed treatment with first-line agents such as metformin, a sulfonylurea, a thiazolidinedione (TZD), or a combination of these agents. The concurrent use of Byetta with insulin has been inadequately studied and its safety has not been established in the scientific studies, and this patient is being treated with basal insulin. Further, this patients records suggest no contraindications to being treated with conventional alternatives such as metformin or a TZD, such as Actos. Since these medications are reasonable alternatives offered by the Health Plan, the necessity of Byetta has not been demonstrated in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

A 25-year-old male enrollee has requested for rhinoplasty for treatment of his nasal airway obstruction.  Findings:  The physician reviewer found that the patients documentation does not describe the internal and external nasal valve status as well as the current status of the septum. These facts suggest that there is deformity that may be contributing to the airway obstruction that may require a functional rhinoplasty. However, there is inadequate documentation to assess whether the patient truly requires a functional rhinoplasty.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a nine-year-old male enrollee has requested authorization and coverage for occupational therapy (OT) with sensory integrationfor treatment of the enrollees gross motor skill and sensory integration deficits.  Findings:  The physician reviewer found that despite its application in the treatment of autism for many years, there are few objective studies showing the benefit of sensory integration. The studies currently in publication deal primarily with the use of sensory integration therapy in the treatment of preschool children ages 18 months to three years. A search of the literature produced no studies which have specifically targeted school-aged children. Given the lack of sound peer-reviewed evidence supporting the efficacy of sensory integration therapy for older school-aged children, it cannot be concluded that such therapy is medically indicated. Treatment through an individualized education plan would be clinically appropriate.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old male enrollee has requested for K-RAS mutation genetic test for evaluation of his recurrent metastatic cancer. Findings:  The physician reviewer found that this test allows oncologists to give the drugs only to the patients who have a reasonable likelihood of benefiting from them. Though the K-RAS may not be universally accepted at this time, it has rapidly been adopted by many oncologists as a medically necessary step prior to administering cetuximab or panitumumab.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a seven-year-old female enrollee has requested inpatient hospitalization services for treatment of the enrollees acute appendicitis.  Findings:  The physician reviewer found that as the Milliman criteria indicate, in the absence of complicated appendicitis found at the time of operation, a patient should be expected to be treated in an ambulatory fashion. These guidelines are similar for pediatric patients (Nadler, et al). Uncomplicated appendicitis in pediatric patients can be treated with a single dose of perioperative antibiotics with discharge expected 24 hours after surgery. On the date indicated, the patient had adequate pain control and was tolerating a clear liquid diet, which would have been the appropriate day of discharge. Therefore, the inpatient level of care services provided from the time frame specified was medically necessary, but the services provided on the subsequent day were not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 35-year-old female enrollee has requested RAST testing for evaluation of her allergies. Findings: Three physician reviewers found that RAST testing for IgG was not likely to have been the most beneficial method of evaluating this patient. Food allergy is due to an IgE-mediated triggering of mediators from cells. Therefore, testing for IgE reactivity is the recommended method of testing. IgG RAST testing for food allergy has not been demonstrated to be beneficial in this clinical scenario.  Reliance on IgG testing may result in over-diagnosing patients with conditions they do not have. The American Academy of Allergy Asthma and Immunology does not support the testing at issue in this patients case. The nature of the tests is non-specific, and as a result, can be applied non-specifically to a wide variety of disorders. All told, RAST testing for IgG was not likely to have been of greater benefit than other available methods of evaluating this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old female enrollee requested authorization and coverage of continued immunotherapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees allergic rhinitis and urticaria.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.