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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gene testing (Decipher Test) for evaluation of the enrollees prostate cancer. Findings: Two of the three physician reviewers found that the request for gene testing is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Decipher is a genomic test that uses a whole-transcriptome microarray assay from formalin-fixed, paraffin-embedded prostate specimens. This signature was developed and validated as a predictor for clinical metastases after radical prostatectomy in men with adverse pathologic features. The main clinical utility of the test is to identify patients with adverse pathologic features who would benefit from salvage radiation therapy. However, data supporting clinical utility of this test in improving outcomes such as prostate cancer mortality, overall survival and treatment side effects in a prospective randomized controlled setting are lacking. The National Comprehensive Cancer Network (NCCN) guidelines recommend consideration of Decipher testing post prostatectomy for patients with pT2 with positive margins, any pT3 or for rising PSA. In this case, the patient does not have any of the adverse pathologic factors. Final Result: The reviewers determined that the requested testing is 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: Reviewers 1, 2, and 3 are board certified in urology 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: Urgent Care
Decision: Overturned

A 53-year-old male enrollee requested emergency services for treatment of his polyneuropathy, organomegaly, endocrinopathy, monoclonal plasma-proliferative disorder, skin changes (POEMS,) abdominal distension, and edema.   Findings:  The physician reviewer found that the enrollee presented himself to the emergency department (ED) when he developed chest tightness and palpitations. The enrollee reported that he was visiting China with his wife and shortly after landing experienced dyspnea and lower extremity edema. The ED note states that the enrollee developed sudden palpitation, chest tightness, dyspnea, shortness of breath and weakness in lower extremities due to tiredness from travel. The ED note also indicates that the enrollee underwent paracentesis in the United States, but abdominal distention was not evidently relieved and became aggravated gradually.  In this case, the enrollee presented to the ED with a diagnosis of POEMS syndrome, and he was symptomatic from abdominal distention. According to the ED record, the enrollee was reported to have palpitation, chest distress, dyspnea, handicapped mobility and weakness of bilateral lower limbs. Thus, the submitted ED records demonstrate that a prudent layperson would have sought immediate medical attention for evaluation and treatment of these symptoms.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee has requested Crestor 20 mg for treatment of his cardiovascular risk.  Findings:  The physician reviewer found that based on the records provided, the patient has some coronary risk and reference to dyslipidemia that is not effectively controlled with simvastatin 20mg daily. There is recent data from the SEARCH collaborative group indicating a significantly higher incidence of myopathy in patients treated with 80mg daily of simvastatin compared to those that received only 20mg daily. Myopathy may be of particular concern in patients taking drugs that potentiate simvastatin levels such as Multaq prescribed to this patient. For this reason, the US Food and Drug Administration (FDA) has issued a warning not to prescribe the higher dose simvastatin to patients who have not previously taken the higher dose for at least 12 months without signs of myopathy. However, there is no report of an increased risk of myopathy using high dose (80mg per day) pravastatin (Pravachol) or high dose (80mg per day) lovastatin (Mevacor). In addition, this patients records do not document that the patient has been prescribed or is intolerant to these medications. Therefore, the use of Crestor in this circumstance is not medically necessary at this time since either Pravachol 80mg or Mevacor 80mg may result in more potent LDL reduction compared to lower dose (20mg per day) simvastatin the patient is currently being prescribed. Accordingly, the requested Crestor 20mg per day has not been shown to be medically necessary in the management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 33-year-old female with a BMI of 52. She has comorbid conditions including hypertension and hydronephrosis with decreased renal function. She wishes to undergo gastric bypass. She has not undergone a formal psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery.With a BMI of 52 and comorbid conditions, the patient meets accepted national medical necessity criteria for consideration of weight loss surgery. Roux-en-Y gastric bypass is medically indicated and medically necessary for treatment of this patients morbid obesity. Furthermore, scientific evidence does not show that structured weight management plans consisting of diet and exercise have been successful in the treatment of the morbidly obese. The study referenced above demonstrates that surgery has the best long-term outcome for the morbidly obese. However, although medically the patient meets criteria for consideration of weight loss surgery, there is no evidence that the patient has undergone a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery. Such an evaluation is considered standard of care prior to authorizing weight loss surgery.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. Therefore, the Health Plans denial should be overturned. If the psychological evaluation indicates the patient is an appropriate candidate for weight loss surgery, the procedure should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery the procedure should not be authorized.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for unilateral breast tomosynthesis for evaluation of the enrollee, who had an abnormality on a prior mammogram. Findings:  The physician reviewers 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.  Considering the dense nature of her breasts, the initial tomosynthesis was warranted.  However, there is a lack of support for the repeat tomosynthesis after only a two-week interval.  The sonogram was critical in excluding a significant lesion.  Thus, unilateral breast tomosynthesis was not likely to be of greater benefit than other methods of evaluating this patient. Final Result: Two of three reviewers determined that the service 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:  Physician reviewer number one, two, and three are board certified in diagnostic radiology 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: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested the Tomatis Method - auditory integration therapy for treatment of the enrollees medical condition.  Findings:  Three physician reviewers found that the Tomatis Method is an auditory integration therapy that has not been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of medical research demonstrating the Tomatis Method is effective in this clinical setting. The study by Corbett and colleagues found that children not receiving Tomatis Method had better language progress than the children receiving the Tomatis Method. Given the lack of support in the peer-reviewed literature, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any standard therapy. Final Result: Three 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:   One reviewer is board certified in pediatrics and child neurology and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in developmental and behavioral pediatrics and is actively practicing.  One reviewer is board certified in child neurology and is 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 33-year-old female enrollee requested authorization and coverage of continued skilled nursing facility services. The Health Plan denied the request indicating that the requested services are 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 services are medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Copaxone for treatment of the enrollees multiple sclerosis.Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the requested medication in this clinical setting. Multiple sclerosis (MS) is a neurological disease mediated by the immune system within the central nervous system. Based upon the documents submitted, the patients clinical history is suspicious for MS and the patient is at a high risk for disease progression.  In this clinical setting, evidence supports disease-modifying therapy. Interferons have shown benefit in patients with both multiple sclerosis as well as in patients that have a high risk of developing multiple sclerosis.  In studies comparing glatiramer acetate with interferon, therapy effects were similar with possible less lesion burden with interferon therapy. The therapies available on the Health Plans formulary include Avonex, Gilenya, Rebif, and Plegridy. These medications have been shown to be effective and equal to if not better than glatiramer acetate (Copaxone). Considering the available evidence, the formulary plan options are medically appropriate for this clinical scenario. Therefore, the requested medication Copaxone is not medically not medically necessary for treatment of this patient.  Final Result: The reviewer determined that the requested medication 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 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: Medical Necessity
Decision: Upheld

A 27-year-old male enrollee requested a 12-week course of Sovaldi 400mg for medical treatment of his hepatitis C.  Findings:  The physician reviewer found that the current medical evidence does not support the requested medication in this clinical setting.  Per the medical records, this patient has minimal to no fibrosis.  The documentation noted that a trichrome stain of the liver was normal.  The requested treatment is not indicated in this patients case.  His fatigue is likely multifactorial and most likely secondary to depression.  This symptom is not an indication for treatment of his hepatitis C.  All told, the requested 12-week course of Sovaldi 400mg is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa (hyaluronan) injections. As evidenced by the history of significant benefit from prior injections, the current literature continues to support the use of viscosupplementation for chondromalacia of the knees. Researchers reported on 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 knee osteoarthritis. Its use 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 chondromalacia. As such, Euflexxa (hyaluronan) injections are medically necessary for treatment of this 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for the platelet rich plasma injections. Review of the available literature on platelet rich plasma for the treatment of knee osteoarthritis fails to demonstrate that the requested treatment significantly changes outcomes or results in better or more durable pain relief than other standard therapies. Currently, there is a paucity of randomized controlled clinical trials demonstrating the safety and effectiveness of platelet rich plasma injections. In addition, side effects, such as post-injection swelling and pain, short duration nausea and dizziness, have been reported in up to 20% of patients. Further, the American Society of Orthopaedic Surgeons (AAOS) clinical practice guidelines for treatment of osteoarthritis of the knee do not support platelet rich plasma injections given the lack of compelling evidence showing improved health outcomes. All told, the platelet rich plasma injections were not likely to be more beneficial for the treatment of the patients medical condition than any other available standard therapy.One reviewer found that the platelet rich plasma injections were likely to be more beneficial for the treatment of the patients medical condition than any other available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were 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: One reviewer is board certified in orthopedic surgery and is actively practicing. One reviewer is board certified in orthopedic surgery and is actively practicing.  One reviewer is board certified in orthopedic surgery and is 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: Upheld

The patient has requested authorization and coverage for a power wheelchair to perform one or more mobility-related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community. The records show the patient underwent bilateral knee replacements and has conditions that would be better addressed through higher levels of physical activity, rather than the lower levels of physical activity that a power wheelchair would encourage. There are no documented impairments that would preclude the use of a manual wheelchair for longer distance community mobility. Therefore, the requested power wheelchair is not medically necessary to perform one or more mobility-related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation 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 Harvoni for treatment of her hepatitis C. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication in this patients case.  Both Harvoni and Viekira Pak are equally safe in pregnancy.  However, ribavirin is pregnancy category X.  Thus, the requested medication Harvoni is medically indicated and is appropriate given the Health Plans alternative.  Additionally, the patients cirrhosis will require a 24-week course of Viekira Pak, whereas the desired Harvoni treatment requires 12-week duration of therapy.  There is sufficient support for the requested medication in this clinical setting.  In this patients case, Harvoni  is medically indicated.  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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for physical therapy three times a week at a skilled nursing facility (SNF). The records provided for review document that this patient has a history of lower thoracic level spinal cord injury since January 2021, with paraplegia, neurogenic bladder, and neurogenic bowel. The primary goals of rehabilitation in this clinical setting are maximizing function given the patients current impairments (Nas, et al.). The patient has undergone extensive rehabilitation but has plateaued functionally at a level where he requires contact guard assistance for transfers, physical assistance for his lower body self-care, and a wheelchair for his mobility at a stand-by assistance level. The patients lower limb motor recovery has been absent to minimal and he does not have the lower body strength whereby functional ambulation is a goal (Chay and Kirshblum). The patient does not require additional physical therapy services as he has plateaued functionally, and he has not demonstrated the ability to improve further with therapy services. The patient can continue with self-directed exercise to improve strength. For these reasons, the requested physical therapy three times a week at a SNF is 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 board certified in physical medicine and rehabilitation 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.