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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma assay.Findings:  Three physician reviewers found that melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for patients with high depth of invasion, 0.76 to 1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on the DecisionDx-Melanoma assay for melanoma has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, DecisionDx-Melanoma assay 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 medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee requested authorization and coverage of a referral to a pain management clinic for the treatment of back pain.  The Health Plan denied the enrollees request indicating that the requested 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 services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 33-year-old male has requested Xifaxan-Rifaximin 550mg for treatment of irritable bowel syndrome.  Findings:  The physician reviewer found that this patient follows the typical course of IBS as his symptoms tend to alternate over time. One treatment strategy for IBS is to use antibiotics for possible bacterial overgrowth. In the medical literature, standard antibiotics, such as metronidazole and TMP-sulfa, are proven to be effective. This patients records do not document the presence of bacterial overgrowth at this time. Further, the patient is variably compliant with Amitiza and current diarrhea, cramping, and bloating may be a side effect from using this drug. All told, the requested Xifaxan-Rifaximin 550mg is not supported as medically necessary in treating this patients medical condition based on the records provided for review
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee has requested continued transcranial magnetic stimulation (TMS) for treatment of her  major depression.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy. In this case, the treating psychiatrists notes do not provide a rationale or specific request for ongoing treatment. Thus, it is unclear if the patient requires maintenance treatment or has yet to complete the initial treatment course. Furthermore, the American Psychiatric Associations (APA) endorsement for TMS is limited to acute phase depression, and this is typically accomplished within 35 sessions. The documentation submitted by the Health Plan indicates the patient has already received 40 sessions of TMS therapy. Based on the documentation provided, and in consideration of opinions from the research community and the APA, continued TMS therapy is not medically necessary for treatment of the patients condition.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested an immediate release (short-acting) opioid including Norco, Percocet or Dilaudid, for treatment of her pain.  Findings:  The physician reviewer found that the current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.  Short-acting opioids such as Norco, Percocet or Dilaudid are associated with a high risk of dependence and tolerance.  All told, the requested immediate release (short-acting) opioid including Norco, Percocet or Dilaudid is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for the HillRom Vest Airway Clearance System being used. The Health Plan has denied this request, indicating that the device at issue is investigational for the treatment of the patients medical condition. The records noted a history of cystic fibrosis, which is complicated by elevated liver enzymes and pancreatic insufficiency. The records noted an acute increase in pulmonary secretions.Findings:  Three physician reviewers found that According to the Cystic Fibrosis Pulmonary Guidelines from the Cystic Fibrosis Foundation, airway clearance therapy is recommended for all pediatric patients with cystic fibrosis (CF). According to researchers, the Cystic Fibrosis Pulmonary Guidelines further indicate that no airway clearance therapy has been demonstrated to be superior to others, so the prescription of therapy should be individualized. Clearance of airway secretions has been a primary therapy for those with CF. This patient has had been using the positive expiratory pressure (PEP) without good results.Final Result: The reviewers determined that the requested device was and is 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: Two out of three physician reviewers are board certified in pediatrics with sub-specialty certification in pediatric critical care, and are actively practicing. One out of three physician reviewers is board certified in internal medicine with sub-specialty certification in pulmonary disease, and 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 digital breast tomosynthesis performed. Findings:  The physician reviewer found that : breast 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, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts were described as very dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Thus, digital breast tomosynthesis performed on the date of dispute was likely to have been more effective than other methods of evaluating this patient. Final Result: The 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.Final Result: The 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: Physician reviewers 1, 2 & 3 are board certified in diagnostic radiology and are actively practicing. The reviewers are all expert sin 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 Cimzia.Findings:  The physician reviewer found that guidelines for the treatment of rheumatoid arthritis recommends the addition of biologic disease-modifying antirheumatic drugs (DMARDs), such as   tumor necrosis factor (TNF) inhibitors like Cimzia, when escalating therapy to optimize rheumatoid arthritis disease control. The guidelines do not indicate a recommendation for a target synthetic DMARD over a biologic DMARD. Mariette and colleagues note that there is minimal to no placental transfer of certolizumab pegol (brand name Cimzia), an Fc-free anti-TNF drug, supporting continuation of treatment with certolizumab pegol during pregnancy when necessary. In this case, the records note that the patient has moderate-to-severe rheumatoid arthritis disease activity after poor response to methotrexate, Enbrel, and Humira. The patient reports that she is planning to get pregnant. In this clinical setting, the requested medication is medically indicated. Therefore, Cimzia is 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 rheumatology 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

The parent of a 13-year-old female has requested Mepron (750mg 300cc with two additional refills) for treatment of her diagnosis of Lyme disease.   Findings:  The physician reviewer found that based on review of the available records, there is inadequate documentation to support the presence of Babesia infection in this patient. Specifically, there is no clinical history that might indicate a reason to consider this diagnosis. In addition, the patients serological tests for Babesia have been either completely negative (the FISH) or at a borderline level of significance (the IFA). Given that the Babesia titer and IFA titers were the same on two dates a month apart, it is likely the results were falsely positive. There is also no support for the diagnosis of any other tick borne disease. All told, the requested medication is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar sympathectomy for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that this patient has a severe form of plantar hyperhidrosis that has already resulted in falls.   It is refractory to conservative treatment strategies.  Per the medical records, this patient is well-informed of the risks of the planned lumbar sympathectomy procedure.  There are limited treatment options in this clinical setting.  Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in 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

The parent of a 13-year-old female enrollee has requested  partial hospitalization program (PHP) services for treatment of the enrollees eating disorder and depression.  Findings:  The physician reviewer found that according to the psychiatric notes, the patient was not medically stable on the said dates, as she had documented evidence of orthostatic hypotension. Additionally, she had subjective complaints of dizziness and dehydration. Her treatment plan was changed to increase her fluids and monitor her for this condition. However, a week later she was no longer experiencing subjective complaints of dizziness and there was no notation in the records indicating that her vital signs still demonstrated hypotension. Therefore, the patient was medically stable at that point in time, and could safely be discharged to a lower level of care. According, continued PHP level of care was medically necessary during the said timeframe; PHP level of care was not medically necessary going forward.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the peripheral nerve blocks for treatment of the enrollees right foot pain. Findings:  The physician reviewers found that treatment for an acute episode of inflammation of the intermetatarsal nerves include shoe changes, orthotics, surgery, and peripheral nerve blocks. This patient has a documented contraindication to treatment with aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs). The care rendered to the patient, including the peripheral nerve blocks are considered standard accepted therapy for orthopedics and podiatry. Final Result: All three reviewers determined that the services at issue were likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Credentials/Qualifications: Medical professional reviewers number one, two, and three are board certified in podiatry and 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 Fasenra (benralizumab, SQ) injections. Fasenra is U.S. Food and Drug Administration (FDA) approved and supported by medical evidence for the management of eosinophilic asthma in patients with persistent asthma symptoms and peripheral eosinophilia who have tried and failed inhaled asthma therapy, including inhaled corticosteroids and inhaled long-acting beta-agonist. Based on submitted records, this patient presents with eosinophilic asthma. The provider has recommended continued treatment with Fasenra for the management of the patients eosinophilic asthma, especially given the patients positive response to this treatment. The patient had a peripheral blood eosinophil count of 714 cells/uL, and persistent asthma symptoms despite inhaled corticosteroids and inhaled long-acting beta-agonists. Given her eosinophilic phenotype, treatment with Fasenra is within the standard of care for the patients condition. For these reasons, the requested Fasenra injections are 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 internal medicine with subspecialty certifications in pulmonary disease and critical care 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: Experimental/Investigational
Decision: Upheld

A 54-year-old male enrollee has requested cervical artificial intervertebral disc surgery for treatment of his degenerative cervical disc disease. Findings:  Three physician reviewers found that the studies to date do not have sufficient longevity to rule out or properly assess the long-term complications associated with particulate wear debris from the device components. It is known through total joint arthroplasty at the hip and knee that complications of osteolysis can lead to loosening and need for revision. The experience of osteolysis is related to individual tissue reactions to particulate debris. The studies to date are not of sufficient length to demonstrate the full effect of artificial disc replacement. In addition to osteolysis and loosening, individual patient reactions can include myositis ossificans and loss of motion. It is not established that the initial improvement in range of motion seen after artificial disc replacement will be maintained over time. In this patients case, the requested cervical artificial intervertebral disc surgery is not likely to be the most beneficial treatment alternative.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 55-year-old male with a body mass index (BMI) of 38.9 and comorbidities including diabetes mellitus, hypertension, and sleep apnea. He has requested authorization for gastric banding weight loss surgery. The Health Plan has denied the patients request on the basis that the gastric banding procedure is not medically necessary.Gastric banding is not considered standard of care. Furthermore, gastric banding surgery is known to have higher complications and greater risk than other weight loss procedures. This patient can be appropriately and effectively treated through other weight loss procedures. The gastric band procedure is not medically indicated for treatment of this patients obesity. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old female enrollee has requested perispinal administration of etanercept for neuroinflammatory disorders for treatment of his pain. Findings:  Two physician reviewers found that based upon the current medical literature, the superior efficacy of the requested services in this clinical scenario has not been established. Many of the articles submitted were not controlled or were case studies or pilot studies. Those that were controlled noted that further investigation was required.  There was one study submitted that involved post-amputation pain, and this was an uncontrolled study of six men.  This treatment only worked in those men whose pain was less than one year duration.  It has not been established that this patients pain is due to sciatica. The medical records consistently indicate that her pain is due to a neuroma. CT scan did not demonstrate any findings of nerve root impingement of the lumbar spine.  Therefore, in this patients case, the requested perispinal administration of etanercept for neuroinflammatory disorders is not likely to be of greater benefit than other available treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested positron emission tomography (PET) scan for evaluation of her medical condition. Findings: Two physician reviewers found that there is sufficient support for the requested services in this patients case.  The patient has had progression of disease while on intensive chemotherapy.  In general, liver metastases can be followed with sequential routine contrast enhanced CT scanning of the abdomen.  However, there is considerable variability in the best approach to diagnosing and following bone metastases.  Routine bone scintigraphy will often produce confusing results during therapy.  A lytic bone metastases might be relatively photopenic at the early stage, and after successful therapy, as the bone is reconstituting and osteoblastic activity develops, the scintigraphic findings might actually suggest worsening rather than improvement.  PET/CT scans offer the ability to image the entire body as opposed to routine CT scans which must be directed to specific body regions.  Considering that this patient has had multiple sequential PET/CT scans, the most efficacious method would be continuing to perform a PET scan for comparison.  In sum, the requested PET scan is likely to be more effective than other methods of evaluating this patient.Final Result: Two reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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.