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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for knee surgery for treatment of the enrollees bilateral knee degenerative joint disease. Findings:  The physician reviewer found that the medical literature, reviewed 13 randomized clinical trials and 12 observational studies and found no long-term difference between patients who underwent arthroscopy with debridement versus patients treated conservatively with regard to pain or function. Another study evaluated the benefits of arthroscopic knee surgery involving partial meniscectomy, debridement, or both for middle aged or older patients with knee pain and degenerative knee disease. The studies concluded that the benefit with intervention was small and inconsequential for degenerative tears and chondromalacia. Taken together, these findings do not support the arthroscopic surgery for older patients with knee pain with or without signs of osteoarthritis. Thus, this patient may be a candidate for a total knee arthroplasty based upon the degree of pain, difficulty with ambulation, lack of response to multiple corticosteroid injections, and magnetic resonance imaging (MRI) findings of tricompartmental osteoarthritis. However, the clinical information does not indicate that arthroscopy will be of benefit in the presence of tricompartmental osteoarthritis as noted on the MRI report. Final Result: The reviewer determined that the requested surgery 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested food allergy testing (IgG food sensitivity test) for treatment of the enrollees fatigue.   Findings:  Three physician reviewers found that the testing at issue is not supported by the peer-reviewed literature. IgG testing for food allergies is not supported by national guidelines. Currently, elevated IgG levels for particular food allergens are thought to reflect prolonged exposure to components of that food, rather than a sensitivity to that food.  While research in this area is ongoing, and may be found to be useful for some indications in future, at this time IgG testing has not been established as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the testing at issue 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: One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. Two reviewers are board certified in pediatrics with sub-specialty certification in pediatric gastroenterology 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 breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that breast tomosynthesis was likely to be more beneficial for this patient than any available standard modalities. Medical studies have shown that the addition of three dimensional (3D) digital breast tomosynthesis (DBT) reduces false positives and increases cancer detection when compared to two dimensional full field digital mammography (FFDM, 2D) alone. Recall rates are reduced by 15-17%: 3D allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue (asymmetries). Studies have also shown that there has been an increase in cancer detection by 33-53%: cancer detection increased from 6 cancers/1000 women screened with 2D to 8 cancers/1000 women screened with 3D. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the use of tomosynthesis for this patients routine breast cancer screening.  Final Result: Three reviewers determined that the service 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:   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.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old female enrollee requested authorization and coverage for eyelid surgery for the treatment of vision impairment.  The health plan has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees medical condition. One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested procedures are medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old female has requested transcranial magnetic stimulation therapy for treatment of her major depressive disorder.  Findings:  Two physician reviewers found that her symptoms include severe depression, anxiety, insomnia, poor concentration, poor energy, fatigue, feelings of hopelessness, and intermittent suicidal ideation.  She has been tried on multiple medications, including Cymbalta, Abilify, Seroquel, Elavil, Lexapro, Prozac, Effexor, Remeron, clomipramine, nortriptyline, Luvox, Zoloft, Desyrel, Celexa, Paxil, Wellbutrin, and Pristiq.  She is currently in psychotherapy and has received cognitive therapy, with minimal to no response.  This patient has major depressive disorder which is been refractory to numerous medication trials and psychotherapy, including cognitive therapy.  Her treating provider has recommended transcranial magnetic stimulation.  The current medical literature has demonstrated the benefit of transcranial magnetic stimulation.  This patient has not responded to conventional medications or procedures for the treatment of her sustained depression.  Transcranial magnetic stimulation has been shown to improve patients with this condition.  In this clinical setting, transcranial magnetic stimulation is likely to be superior over other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old female enrollee has requested speech therapy for treatment of the enrollees speech disturbance. Findings:  The physician reviewer found that cerebral palsy is a non-progressive encephalopathy that occurs early in life and results in numerous neurologic, motor, and postural deficits in the developing child. Children with cerebral palsy frequently have seizures, as well as speech and language delays, visual impairments, and cognitive delays. Secondary deficits in sensory and psychosocial skills may also result. Early intervention using a team approach optimizes each childs potential for development and prevention of secondary deficits. Members of the team typically include a pediatrician, neurologist, occupational therapist, physical therapist, and speech and language pathologist.  This patient has multiple medical problems, including cerebral palsy, developmental delay, seizure disorder, dysphagia, and expressive and receptive language delay. Her speech and language skills fall significantly below those of other children her age, negatively impacting her ability to communicate effectively with peers and adults.  She has been using a variety of alternative augmentative communication devices, and her recent evaluation revealed the ability to gain additional vocabulary skills.  Speech therapy is standard of care in this clinical scenario. All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for chiropractic services. Researchers state that spinal manipulation therapy (SMT) produces similar effects to recommended therapies for chronic low back pain. Medical literature states that there is moderate quality evidence supporting SMT and mobilization to reduce pain and improve function for patients with chronic low back pain. This patient has a history of lower back, neck, and right shoulder pain. Current research has shown that SMT is safe and beneficial for chronic low back pain, and comparable in effectiveness to medical care. The patient reported that chiropractic care has been the only proven and non-invasive medical service that relieves her chronic pain. Given these findings, the requested chiropractic services are medically necessary for 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 a licensed chiropractor, board certified in oriental medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400 mg 100 mg for 12 weeks for treatment of his hepatitis C. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions.  This applies regardless of fibrosis stage.  Per the guidelines, Epclusa is recommended as first-line therapy for treatment-naive, genotype 2 patients.  The medical evidence indicates that a delay in treatment may result in decreased survival. Final Result: The reviewers determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Prometheus Anser IFX (measurement of serum infliximab and the antibodies to infliximab) for evaluation of the enrollees ulcerative colitis.  Findings: Three physician reviewers found that the superior efficacy of the services at issue has not been demonstrated.  The Anser IFX test was ordered to determine the cause for possible loss of response to Remicade.  The use of Anser IFX testing to direct subsequent management has not been clinically proven to improve patient clinical outcomes or alter patient management in high-quality controlled clinical trials.  The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold drug levels been established.  Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response.  Although loss of response to infliximab is common, there was a lack of standard guidelines defining a therapeutic strategy at the time of testing.  A systematic review by Yarur and colleagues noted that future prospective controlled studies are needed, especially considering anti-tumor necrosis factor levels are influenced by several variables that can fluctuate over time and among individuals.  Thus, Prometheus Anser IFX testing was not likely to have been of greater benefit than other methods of evaluating this patient.Final Result: Three 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 60-year-old female enrollee has requested Erbitux for treatment of her metastatic vulvar carcinoma with multiple pulmonary metastases. Findings:  The physician reviewer found that off-label use of chemotherapy agents, especially in stage IV disease, needs to show some phase I/II data that are promising.  In this patients case, her tumor is so rare that one cannot expect that kind of evidence.  Due to the rarity of this disease, there is limited evidence in the peer-reviewed literature relating to the condition.  However, the report by Richard and colleagues provides support for the requested medication in this patients case. In this report, the authors discussed a case of widely metastatic vulvar cancer that derived a partial response from cisplatin and cetuximab combined.  There was evidence for palliation of symptoms in this case. In this patients case, she has progressed on prior chemotherapy regimens, and most chemotherapy regimens have no effect on this adenocarcinoma.  There is no standard alternative for the treatment of this patient. In this clinical scenario, Erbitux is medically indicated.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency services.  This patient presented with neck pain radiating into the left upper extremity with associated numbness. The records documented a progression of symptoms to include pain radiating into the bilateral upper extremities and onset of lower extremity pain. The patient was referred for an in-network spine surgeon and was seen in consultation. The patient was also evaluated by an out-of-network spine surgeon. Clinical examination findings were consistent with imaging evidence of disc pathology with severe stenosis at C5-6 and C6-7 and electrodiagnostic evidence of acute C6 and C7 radiculopathy. There was no imaging evidence of cord signal change. Both providers recommended two-level anterior cervical discectomy and artificial disc replacement. The records documented that the patient proceeded with anterior cervical discectomy and artificial disc replacement at C5-6 and C6-7 with the out-of-network provider. There is evidence that the patient presented with a frank progressive neurologic emergency between the initial examination and surgery to support this as an emergent surgery, as defined by California law. The services at issue were necessary for treatment of an emergency medical condition. Thus, the patient received emergency medical services on the date(s) of service at issue.Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections in both knees.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. 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 and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. 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 when everything else has been tried and the options are limited. In this case, the patient has tried and failed other conservative treatments for patellofemoral chondromalacia including physical therapy and injections in the past. The patient is refusing additional corticosteroid injections and requesting viscosupplementation. The patients degenerative changes are also not severe enough to warrant surgery. Under these circumstances, the requested Orthovisc injections in both knees are medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for the 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 stereotactic body radiotherapy (SBRT). Findings:  The physician reviewer found that as noted by the National Comprehensive Cancer Network (NCCN), the standard treatment for patients who have a rising PSA following radiation therapy is with hormone therapy or chemotherapy. There is a lack of evidence to suggest that a course of SBRT will improve outcomes in patients with prostate cancer . In some cases, patients with colorectal or lung histologies with limited metastatic disease may be eligible for SBRT. However, there is a paucity of medical evidence that suggests that patients with prostate cancer benefit from SBRT. The standard of care for patients with prostate cancer is systemic treatment with hormone therapy or chemotherapy. Accordingly, the requested SBRT is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 & 3 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for corneal collagen cross-linking for treatment of his keratoconus. Findings:  Three physician reviewers found that treatment for this patients condition with corneal collagen cross-linking was appropriate and consistent with current medical guidelines. Based on the patients diagnosis and progression, cross-linking was indicated as the most effective treatment option available. Although there are deficiencies in the individual studies on corneal collagen cross-linking, there is data available to support cross-linking as a safe and effective procedure for stabilizing corneal ectasia and potentially delaying or preventing the need for full-thickness corneal transplant. Furthermore, corneal collagen cross-linking for corneal ectasias fulfills an unmet need. There is no other treatment option available to slow or halt disease progression. Given this support, the corneal collagen cross-linking provided was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Review: Three reviewers determined that the service at issue was 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 ophthalmology and are actively practicing. The reviewers are 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 35-year-old female enrollee has requested Ampyra for treatment of her multiple sclerosis.  Findings:  The physician reviewer found that based on review of the available records, this patient has multiple sclerosis with gait disorder. She showed an improved functional status with Ampyra, in terms of walking speed, balance, and endurance. Further, the records document the patients functional status decreased performance on the 25-foot timed walking test after she discontinued Ampyra for six days. Given the patients progressively worsening status and her improvement with Ampyra, the requested medication is supported as medically necessary for treatment of her medical condition.