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

The enrollee is requesting authorization and coverage for Acthar Gel. The enrollee has a diagnosis of membranous glomerulonephritis. An assessment note reports the enrollees disease process is associated with a rising creatinine, and that the enrollees prognosis at the current time would appear to be poor even with immunosuppressive therapy. The provider ordered Acthar gel for the enrollee. The providers appeal letter noted tacrolimus, cyclosporine, rituximab and mycophenolate would all have adverse effects on the enrollee. A review of the literature shows Acthar gel is an approved medication for the treatment of proteinuria associated with nephrotic syndrome, and is considered a viable treatment option for this enrollee whose renal condition has worsened on a standard treatment regimen. Considering that this enrollee has tried and failed on immunosuppressant mediations, Acthar Gel is considered medically necessary to treat this enrollees refractory nephrotic syndrome.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in nephrology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right ring finger and middle finger trigger release and right partial palmar fasciectomy. This patient presents with a history of hand pain following a hyperextension injury of the right ring and middle fingers. She reports difficulty using her hand. Her past medical history is positive for type 1 diabetes. There is intact function of all distal flexors and extensors. There were no median or ulnar nerve compression findings or sensory deficits. A recent right hand MRI documented a thin rim of peritendinous edema surrounding the flexor tendons of the index, middle, and ring fingers without tendon sheath effusion. Conservative treatment had included splinting, Tylenol, and nonsteroidal anti-inflammatory drugs, with mild improvement. She had a corticosteroid injection for possible ring and middle trigger fingers, with temporary relief followed by worsening. Hand therapy has been recommended, but not completed. She has undergone multiple consultations, with no surgical treatment recommendations. She underwent an out-of-network provider who recommended middle and ring trigger finger release surgery and partial palmar fasciectomy. There is no current evidence of active triggering or contracture in the right middle and ring fingers to support the medical necessity of trigger finger release surgery. There is no documentation of significant Dupuytrens contracture to support the medical necessity of partial palmar fasciectomy at this time. Therefore, the requested right ring finger and middle finger trigger release and right partial palmar fasciectomy are not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The 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

The parent of a 10-year-old female enrollee has requested Supprelin LA implant for treatment of the enrollees diagnosis of precocious puberty.  Findings:  The physician reviewer found that Supprelin LA was approved by the Food and Drug Administration (FDA) in 2007 for treatment of central precocious puberty. Although this patient experienced onset of puberty at an age older than the cutoff of 8 years, her puberty is noted to be progressing at a rapid pace. With progression in skeletal maturation, she is expected to have a shorter and shorter predicted adult height over time. As she started out with short stature due to SGA and familial causes, further compromise in her adult height on the basis of her precocious puberty is apt to result in an even poorer predicted adult height. Her current predicted adult height falls between 54 to 56 inches, which is more than 3 standard deviations below normal for an adult female. Administration of Supprelin results in decreased levels of luteinizing hormone (LH) and FSH, thus suppressing puberty and further advancement in skeletal maturation. Treatment for precocious puberty is medically necessary both to prevent premature epiphyseal fusion and to prevent further progression in pubertal development, allowing time for GH to have an effect while her growth plates are still open. In addition, clinical data has demonstrated that the Supprelin implant consistently suppresses clinical and laboratory parameters of precocious puberty for at least one year while avoiding the pain and inconvenience of monthly injections. Thus, the requested Supprelin LA implant has been established as medically necessary for management of this patients precocious puberty.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 23-year-old male with a long history of polysubstance abuse, including prescription medications, since the age of 12. He was admitted to a residential treatment program in November 2005 and later discharged after testing positive for opiates. His prior residential treatment admission and intensive outpatient (IOP) attempts at treatment resulted in non-compliance. Based on the information provided, he was not suicidal, homicidal or psychotic. A request has been made for reimbursement for residential treatment services provided from November 2005 through January 2006. The Health Plan has denied this request on the basis that the services at issue were not medically necessary.The Health Plans denial should be upheld. Records indicate the patient was non-compliant with treatment and did not benefit from the program. Furthermore, the services offered by the Health Plan were medically reasonable and appropriate. The patient could have been appropriately treated in a day treatment chemical dependency program along with the medication Effexor and weekly individual psychotherapy. Based upon the evidence provided, the level of care the patient received was not medically warranted. Accordingly, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: ean nrollee has requested authorization and coverage for Zepatier 50/100 mg at a quantity of 28 per 28 days for 12 weeks. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies regardless of fibrosis score. The guidelines recommend that treatment naive genotype 1b patients should be treated with Zepatier for 12 weeks, regardless of NS5A resistance testing results. These guideline recommendations are based on high quality clinical trial data. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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 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 21-year-old female enrollee who has requested authorization and coverage for breast reduction surgery. The health plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees very large breasts.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: Experimental/Investigational
Decision: Upheld

A 57-year-old female enrollee requested KRAS and BRAF genetic testing for medical evaluation of her colon cancer.  Findings:  Two physician reviewers found that the testing was not likely to be more effective for this patient than other available treatment options. The medical literature does not support the services in this clinical setting. The testing is indicated for metastatic disease when treatment with chemotherapy is to be initiated. In this case, the patient presents with no evidence of metastatic disease. As such, the services were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old male enrollee requested authorization and coverage for peglyated interferon (PEG-Intron).  The health plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees chronic hepatitis C.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 34-year-old male enrollee requested authorization and coverage of a non-myeloablative matched unrelated allogenic stem cell transplant for the treatment of Hodgkins disease.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that a non-myeloablative matched unrelated allogenic stem cell transplant is likely to be more beneficial for treatment of the enrollees Hodgkins disease than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization overturned the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 13-year-old male enrollee has for Nutropin AQ 10mg/2ml for treatment of the enrollees short stature.   Findings:  The physician reviewer found that From the standpoint of the FDA, GH is not indicated for those children whose predicted adult height is greater than 160 cm. Based on the information provided, the patients predicted adult height is near 510 (177 cm), and therefore the patient does not qualify for treatment with GH therapy under the FDA guidelines.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Anser ADA blood test. Findings:  Two of the three physician reviewers found there is a lack of support for the services at issue in this clinical setting. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear. Some evidence exists that low serum levels of adalimumab or the presence of adalimumab antibodies have an adverse effect on the clinical outcome of a patients response to treatment. However, there is a lack of well-controlled clinical trials to confirm that use of the Anser ADA testing leads to improved patient outcomes or quality of life as opposed to the standard methods of treatment. The clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. Limited retrospective evidence describes changes in management after measurement to anti-drug antibodies, but does not compare these management changes to those made in the absence of anti-drug antibody measurement. It has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. Diminished or suboptimal response to adalimumab can be managed in several ways, including shortening the interval between doses, increasing the dose, switching to a different anti-tumor necrosis factor agent (in patients who continue to have loss of response after receiving the increased dose), or switching to a non-anti-tumor necrosis factor agent based on clinical observation in lieu of Anser ADA testing. The medical evidence has not demonstrated the superior effectiveness of the services at issue in this patients case. All told, Anser ADA blood test was not likely to have been of greater benefit than other methods of evaluating this patient. 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 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for bilateral, ultrasound-guided Supartz injections to the elbows.Viscosupplementation is an effective therapeutic strategy in early stages of arthropathy, with no complications and long-term good clinical results. In a study of hemophilic patients by Carulli and colleagues, 10 patients with arthritic elbows were treated with viscosupplementation with a good result. Clegg and colleagues report that, A multimodal approach for the treatment of osteoarthritis of the knee with viscosupplementation provides good efficacy for pain relief and return to function when used in an active population. In this case, prior injections of Supartz in both elbows produced good results. Furthermore, the patient has tried and failed other conservative treatments, including activity modification, home exercise program, and corticosteroid injections. As such, the patients options are limited. Additionally, ultrasound guidance provides accurate delivery of viscosupplementation injections. Therefore, bilateral, ultrasound-guided Supartz injections to the elbows are medically necessary for the treatment of the patients medical condition.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 60-year-old male enrollee has requested proton beam radiation therapy for the treatment of his prostate cancer. Findings:  The physician reviewer found that this patient would be deemed as having an intermediate risk prostate cancer based on his Gleason score of 7 (National Comprehensive Cancer Network (NCCN)).  Had it remained at 6, this would be more favorable and would have placed him in the low recurrence risk category. Following NCCN guidelines for intermediate risk patients whose life expectancy is greater than 10 years, treatment would include radical prostatectomy or radiation therapy, with or without androgen deprivation therapy, with or without brachytherapy boost. Brachytherapy alone would not be indicated. Guidelines within the NCCN for radiation therapy indicate for intermediate risk patients, doses of 75 Gy or greater are beneficial and should be delivered with conformal beam approach.  The current guidelines do not indicate that proton beam irradiation is superior over photon beam irradiation. Standard of care options are currently available within the Health Plan. Proton beam radiation therapy is not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old female enrollee has requested artificial disc replacement surgery for treatment of her symptomatic lumbar disc disease with radiculopathy at L5-S1.   Findings:  Three physician reviewers found that the PRODISC-L Total Disc Replacement was approved by the FDA in 2006 for spinal arthroplasty (replacement) in patients with degenerative disc disease.  This approval was based on a non-inferiority rather than superiority study comparing 162 randomized patients treated with PRODISC-L and 80 control patients.  The main conclusions of the study were that at 24 months, the overall incidence of adverse events occurring in the PRODISC-L group was no worse than in the control group, the number of device-related adverse events in the PRODISC-L group was no worse than in the control group, and the overall success rate of the PRODISC-L group was no worse than that of the control group, with a non-inferiority margin of 10%, using FDAs criteria for overall success.  The results of this trial were published in 2007 but there were unexplained discrepancies in the number of subjects reported upon when compared to the number presented to the FDA (Zigler, et al). There have not been any other randomized controlled clinical trials published to date. Given the unknown long term safety and efficacy of the device, in its approval, the FDA requested a post-approval study to obtain a total of five year follow-up data from all subjects in the clinical study. One case series study with longer follow-up, (Shim, et al) followed 24 patients for greater than 3 years and concluded that the facet joint of the index level and the disc at the adjacent level showed an aggravation of the degenerative process in a significant number of patients, 32% and 28.6%, respectively, raising concerns of possible late consequences of total disc replacement, especially regarding facet arthrosis and adjacent segment disease. Given the overall lack of long term safety and efficacy data, artificial disc replacement has not been shown to be a superior option to standard interventions. It is therefore not likely to be more beneficial for treatment of the patients low back and leg symptoms than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 10-month-old female has requested a laser frenulectomy procedure for treatment of the enrollees condition.  Findings:  The physician reviewer found that given that two of the providers who evaluated the patient noted findings describing a thickened frenulum (posterior ankyloglossia), it is likely that this was an appropriate diagnosis. As reported in the relevant medical literature, the posterior ankyloglossia can sometimes be missed (Chu and Bloom). For treatment, laser has been found to be an effective method of improving the difficulties secondary to this medical problem (Puthussery, et al). The thickened short frenulum can be treated with other methods, but considering that this patient has improved since the laser frenulotomy, the requested laser frenulectomy has been demonstrated to be medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 46-year-old woman with a family history of breast cancer involving her mother and sister. On a recent mammogram suspicious microcalcifications were identified in the central aspect of the right breast. A stereotactic biopsy was attempted but the calcifications could not be targeted. A follow-up mammogram in three months was recommended. The patient has requested authorization and coverage for a nuclear scan of her breast to further evaluate for cancer. The Health Plan has denied the request.There is no nuclear medicine breast scan at this time that is used to diagnose primary breast cancer. In the past, technetium-99m-sestamibi scintimammography was evaluated as a possible diagnostic test for breast cancer. However, it became clear that this test was not sufficiently sensitive for the diagnosis of small breast cancers (sensitivity of approximately 80%). FDG-PET scan, which is another nuclear medicine scan, also is not sufficiently sensitive to diagnose small, primary breast cancers. The lower sensitivity is likely caused by a minimum size requirement of approximately 1cm for detection by PET scan and a relatively normal to minimally increased metabolic rate for certain tumor types (e.g., lobular carcinomas and ductal carcinoma in situ). Thus, there is no evidence that the nuclear breast scan requested by the patient is medically indicated.Based upon the information set forth above, I have determined that the requested scan is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.