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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the DecisionDx-Melanoma test that was received. The Health Plan has denied the service at issue as investigational for patients with melanoma.Findings:  Three physician reviewers found that the American Society of Clinical Oncology (ASCO) and Society for Surgical Oncology guidelines recommend sentinel lymph node (SNL) biopsy for patients with intermediate thickness cutaneous melanomas with Breslow thickness 1 to 4 mm of any anatomic site. Routine use of SNL biopsy in this population provides accurate staging, with high estimates for proportion successfully mapped and acceptable estimates for false-negative rate, post-test probability negative and predictive value positive. The patient was assessed with a Breslow thickness 3.2 mm melanoma tumor. The most appropriate test to determine the prognosis related to the patients diagnosis of a malignant melanoma was an SNL biopsy. The use of DecisionDx-Melanoma testing is not the appropriate next step for determination of risk of recurrence and prognosis in a patient with undetermined lymph node status. The record does not indicate that the patient was ineligible for SNL biopsy. The DecisionDx-Melanoma molecular test does not substitute for the determination of risk of sentinel node positivity. Thus, the DecisionDx-Melanoma test received on was not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The 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 reviewers 1, 2 and 3 are board certified internal medicine with subspecialty 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xyrem 500 mg/ml solution, 4.5 grams oral, two (2) times daily, 30-day supply. The submitted documentation supports the medical necessity of the requested medication regimen. Xyrem is FDA approved for treatment of two common symptoms of narcolepsy: excessive daytime sleepiness (EDS) and cataplexy. Alshaikh and colleagues have noted that narcolepsy patients on Xyrem have significant reductions in cataplexy and daytime sleepiness. Xyrem is well tolerated in patients with narcolepsy, and most reported adverse events were mild to moderate in severity. Boscolo-Berto and colleagues have also demonstrated, through meta-analysis of multiple peer reviewed studies, the effectiveness of Xyrem in treating major, clinically relevant narcolepsy symptoms and sleep architecture abnormalities. In this case, the medical records reflect that the patient has a long-standing diagnosis of narcolepsy that has been treated successfully with Xyrem since 2008. Records reflect that the patient has responded well and is well controlled on the medication. Under these circumstances, Xyrem 500 mg/ml solution, 4.5 grams oral, two (2) times daily, 30-day supply is medically necessary to treat the patients medical condition.Final Result: The reviewer 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 psychiatry 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 two-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that this young patient has an identified delay in expressive speech of greater than 50% and a delay in pragmatic skills of 25%. Consistent with the recommendations in the medical literature, speech therapy is indicated for patients who present with any delay greater than 25%. Extensive review of the literature including meta-analysis by Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Further, Gallagher and Chiat evaluated speech and language interventions for 24 preschool children with specific language impairment. The authors reported statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an 8-month period when compared to no intervention or nursery-based intervention. This patient continues to display expressive and receptive language impairment with decreased acquisition of language skills. Based on the foregoing discussion, the requested speech therapy is medically necessary in the treatment of this patients medical condition and should therefore be approved.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee requested authorization and coverage of the medication Evista for the treatment of bone thinning as a result of menopause.  The health plan denied the enrollees request indicating that the requested medication 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 medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Stelara. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. A letter from the provider indicated an adverse effect of frequent injections from Enbrel or Humira. However, the submitted records do not document a treatment trial with Enbrel or Humira nor do the records document which adverse effects were experienced with these medications. Consequently, there is no clear indication that Enbrel or Humira would not be an effective treatment option for this patient. In this patients case, other effective therapies may be available. As such, Stelara is 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 dermatology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for TACE (transcatheter hepatic arterial chemoembolization) procedure for treatment of the enrollee who is diagnosed with bilateral breast cancer metastasized to the liver. Findings: Two physician reviewers found that her main site of metastases has been the liver. Her liver lesion was poorly differentiated adenocarcinoma with high expression of estrogen receptor. She had been managed on Doxil but then experienced an increase in liver tumors. The treating provider recommended TACE (transcatheter hepatic arterial chemoembolization) procedure as next step treatment options. The Health Plan denied the requested procedure noting that this procedure is investigational/experimental for the treatment of this patients medical condition. The medical evidence indicates that TACE is not a targeted therapy used for certain tumors only. TACE is commonly used for metastatic liver tumors which are not responsive to systemic chemotherapy like ocular melanomas, gastric cancers, carcinoid tumors, and others. The survival of patients with metastatic breast cancer is variable and local resection of metastases is considered standard of care, in some instances such as the case under discussion. The approach to stage IV breast cancer and liver-directed therapy has been reviewed in clinical studies and the evidence suggest a survival advantage in such patients when TACE is used as a treatment option. Therefore, in this patients case, the medical evidence supports the superior efficacy of this procedure over the other available treatment options.Final Result: The reviewers determined that the requested procedure is 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 internal medicine with sub-specialty certification 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: Overturned

The patient is a 16-year-old female with an eating disorder who required acute inpatient hospital services. Relevant to that care was a body weight of only 64% of ideal body weight (IBW) and severe hypophosphatemia and severe bradycardia with heart rates as low as 30 beats per minute.  Her primary care provider noted that during her outpatient medical follow-up. her weight dropped consistently and her vital signs remained marginal.  Both the inpatient and the outpatient specialty providers stated the patient required close medical, psychiatric and nutritional follow-up.  The patient did receive post-discharge Eating Disorder specialty care. Her parents are now requesting reimbursement for the specialty medical care provided and continued authorization and coverage for Eating Disorder specialty medical care and nutritional counseling.  The Health Plan denied the parents request based upon a determination that Eating Disorder specialty services are not medically necessary.There is general agreement within the pediatric community that anorexia nervosa is a complex illness with manifestations in both the psychiatric and medical realms. General pediatricians are often ill prepared and hesitant to treat adolescents with this condition. The primary care pediatricians role in this context is more typically to aid in the identification of the problem and to then assist the family in accessing the needed specialized care.  The American Academy of Pediatrics released a policy statement in 2003 regarding this illness. The following sections are relevant to the issue under review:Management of medical complications, provision of nutritional rehabilitation, coordination of psychosocial and psychiatric aspects are often handled by pediatricians who have expertise or experience in the care of adolescents with eating disorders.  other than the most severely affectedmost children and adolescents will be managed in the outpatient setting by a multidisciplinary team coordinated by a pediatrician or subspecialist with appropriate expertise in eating disorders.There is no question that an adolescent with disease of such severity as to require urgent hospitalization and then readmission to a residential treatment facility due to post-discharge decompensation, has a medical need for providers expert in, not just familiar with, the treatment of adolescents with eating disorders.  Specialty medical care and nutritional counseling are medically appropriate for this patient.Based upon the information set forth above, I have determined the services at issue are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 27-year-old female enrollee has requested for partial hospitalization services for treatment of her bipolar disorder, bulimia, panic disorder, polysubstance abuse and attention deficit disorder (ADD). Findings:  The physician reviewer found that there is no evidence that the patients treatment plan is being re-evaluated and amended.  There is no documentation of serious risk on the patients part.
Appeal type: Medical Necessity
Decision: Overturned

A 30-year-old female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is not medically necessary for the treatment of the enrollees migraine headaches.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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the inpatient psychiatric hospitalization services for treatment of his social anxiety and depression. Findings:  The physician reviewer found that the records document that this patient was not in withdrawals. He was not a danger to himself or others, and he was not gravely disabled. He was cognitively intact and attending to his ADLs. His appetite and sleep were moderate to good. He was medically stable. Psychiatrically he could have been treated at a lower level of care. The patients social interaction was improving, engagement in his treatment plan was improving, and he was cooperative and compliant with his medication regimen, albeit in a perseverative and ruminative fashion. He did not demonstrate impulsive behavior on any level. There was no evidence of imminent risk requiring inpatient stay. Discharge plan was for PHP in his area. He no longer required the structure of inpatient level of care and he could have continued treatment on an ambulatory basis. Final Result: The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in addiction 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: Upheld

Nature of Statutory Criteria/Case Summary:  The patient has a history of blepharitis and has failed treatment with eyelid hygiene and topical steroids. While treatment with oral doxycycline and a lower anti-inflammatory dosage is supported, the records do not demonstrate that the patient would experience side effects with the standard form of the drug. As the standard form of this medication is typically tolerated without side effects, the delayed-release form of the medication is not medically indicated. Therefore, doxycycline hyclate delayed-release is not medically necessary for the treatment of this patient. Final Result: The reviewer determined the medication at issue 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 ophthalmology 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 eight weeks for treatment of his hepatitis C virus (HCV).  Findings:  Two physician reviewers found that denying treatment for a chronic disease such as HCV, because the patient does not have an advanced stage disease is not supported by the peer-reviewed literature. The U.S. Food and Drug Administrations (FDA) label on the approved uses for Harvoni does include early stage disease. Thus, the recommendation is not to deny patients treatment if they have early stage disease but to provide treatment to avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from HCV.  Moreover, treatment delays may decrease the benefit of sustained virologic response (SVR). In a report by Jezequel and colleagues of long-term follow-up of 820 patients with biopsy-confirmed stage F0 or F1, a 15% rapid progression of fibrosis was noted, as compared to those who were treated earlier where the long-term survival was better. Specifically, at 15 years, survival was 92% for those with an SVR versus 82% for treatment failures and 87% for those not treated. This was corroborated in many studies. Per American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment guidelines, Harvoni is recommended for treatment-naive patients with HCV genotype 1 infection. Moreover, post-hoc analysis has revealed that non-cirrhotic HCV genotype 1 patients who are treatment naive and have a viral load of less than 6,000,000 IU/mL can be treated with an eight week course instead of 12 weeks and achieve similar cure rates. Therefore, Harvoni for eight weeks is medically necessary based on national guidelines.  Final Result: Two reviewers 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:  One reviewer is board certified in gastroenterology and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in 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

A 63-year-old female enrollee has requested a single photon emission computed tomography/computed tomography (SPECT/CT) scan for evaluation of her diagnosis with hyperparathyroidism. Findings: Three physician reviewers found that the services at issue were likely to have been more efficacious than other options for evaluating this patient.  There is sufficient support for the SPECT/CT scan in this case.  Preoperatively, surgeons must determine the location of the parathyroid gland and whether there is evidence of ectopic parathyroid adenoma.  The SPECT/CT scan is a well-established modality in this clinical setting.  All told, the SPECT/CT scan was likely to have been more effective than other methods of evaluation.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old female enrollee has requested for cervical artificial disc replacement for treatment of her degenerative disc disease. Findings:  Three physician reviewers found that there is no evidence to support multi-level disc replacement. Although disc replacement may some day be proven more beneficial than fusion, there is still insufficient evidence to support the long-term safety and efficacy. Total disc replacements have not been tested in truly blinded studies and there is no long-term data on the superior efficacy of this procedure.
Appeal type: Medical Necessity
Decision: Upheld

The patient is an 85-year-old female who was transferred to a SNF following hospitalization for treatment of pneumonia. In addition, the patient had multiple comorbidities including dementia and functional decline. While in the SNF, the patient received skilled physical and occupational therapy from 6/1/04 to 6/16/04. The patient made minimal gains during this time period except in endurance. Endurance training does require receipt of services from skilled personnel. The patient remained in the SNF until 7/8/04. The Health Plan has denied coverage for the services the patient received from 6/18/04 to 7/8/04. The patient did not make any clinically significant gains after 6/1/04. Skilled rehabilitation services are provided with the goal of enabling a patient to reach maximum functional status. Once maximum functional status is reached, it is reasonable to provide continued endurance training at a non-skilled level. The records provided demonstrate the patient had reached maximum functional status by 6/1/04 and there was no indication that continued therapy would benefit the patients condition. In fact, the records provided demonstrate the continued therapy did not increase the patients functional level. Therefore, 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: Upheld

A 36-year-old female enrollee has requested for a full-body MRI, DEXA scan, mammogram and a thyroid evaluation for treatment of her multiple medical conditions. Findings:  The physician reviewer found that the patient has no clinical indication for a full body MRI. There is no indication in the literature for the use of full body scanning in the screening of patients who do not have symptoms suggestive of a disease due to the low rate of finding disease, and the inconclusiveness of the cause of the abnormality seen. The current literature does not establish a clear benefit to whole body CT or MRI for health screening. The reviewed documentation established no clinical evidence for the requested MRI scan.Moreover, the patient does not meet the clinical criteria per accepted standards of medical practice for the requested procedures: full-body MRI, DEXA scan, mammogram, and thyroid evaluation.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee has requested for apheresis platelets for treatment of her lateral epicondylitis. Findings:  Two physician reviewers found that [latelet-rich plasma has been used in maxillofacial and plastic surgery since the 1990s, and has been employed for treatment of tendinopathy, with mixed results.  Some reports of benefits with injection for lateral epicondylitis have been encouraging, but the need for further study has been noted.  Other studies have not demonstrated any advantage over saline injections.  Additional studies are needed to establish the superior efficacy of the requested services in this patients case.  All told, the requested services are not likely to be of greater efficacy than other treatment options in this case.
Appeal type: Experimental/Investigational
Decision: Overturned

A 56-year-old female enrollee requested rhizotomy (radiofrequency neurolysis) of the sacroiliac joint for medical reatment of her back pain.  Findings:  Three physician reviewers found that radiofrequency neurolysis is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient has had positive results with facet joint injections. In addition, the medical literature supports the requested services in this clinical setting. Therefore, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.