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

A 45-year-old female enrollee has requested pulsed radiofrequency neurolysis treatments for treatment of her peripheral neuropathy. Findings:  Two physician reviewers found that on reviewing the medical literature, Day and colleagues evaluated the role of sympathetic blocks and neurolysis for chronic pain syndromes including neuropathic pain and found that the efficacy of these treatments in providing analgesia for various sympathetic mediated pain syndromes is sparse in the literature. Further, many case reports and case series have been published but few placebo-controlled, blinded studies have been conducted to reliably ascertain its effectiveness. Additional treatment for peripheral neuropathy includes antidepressant therapy. It remains one of the standard therapies for peripheral neuropathy of all types including diabetic, HIV, and idiopathic neuropathy. Max and colleagues performed randomized, double-blinded, cross-over studies in patients with painful diabetic neuropathy, comparing amitriptyline with desipramine. The authors concluded that desipramine relieves pain caused by diabetic neuropathy with similar efficacy to amitriptyline, offering alternatives to patients unable to tolerate one of the two medications. The mechanism of action in antidepressant analgesia for painful neuropathy include blockade of norepinephrine reuptake.This patient may have received some benefit from pulsed radiofrequency neuromodulation of the lumbar sympathetic plexus, however, it is difficult to make argument for reimbursement of the procedures because they are still considered investigational in the medical literature. Thus, the use of pulsed radiofrequency neuromodulation was not and is not likely to be more beneficial for treatment of this patients peripheral neuropathy since the patient has not exhausted all available standard therapies and its use was appropriately determined to be investigational in this clinical setting.
Appeal type: Urgent Care
Decision: Overturned

A 63-year-old male enrollee has requested for emergency services were required on an emergent basis. Findings:  The physician reviewer found that a prudent layperson would have sought medical attention for an increased low back pain following a recent fall. However, the patient did not have an emergency medical condition that placed him in serious jeopardy if he did not undergo surgery. He did not have a serious impairment of bodily function or a serious dysfunction of any bodily organ or part. Failure to have performed his surgery would not have harmed him. The medical records fail to indicate any evidence of instability, angulation, spondylolysis, spondylolisthesis, fracture, tumor, or infection.  The patients symptoms met prudent layperson criteria for emergency care. However, the hospital admission and services provided did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Yaz for treatment of her bleeding with other birth control medications.  Findings:  The physician reviewer found that for the symptoms that the patient has described, most oral contraceptive pills will improve her symptoms. However, there is evidence that those oral contraceptive pills with drospirenone are superior for women with for acne and premenstrual mood deterioration. As this patient has tried multiple oral contraceptive pills including the formularys generic for Yaz, without adequate control of her symptoms, it is reasonable for the patient to be continued on Yaz as it provides the best control of her symptoms. Also, taking the medication in a continuous manner works to improve migraine symptoms. For the reasons provided, the request for Yaz is medically necessary for treatment of the patients medical condition. 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 obstetrics and gynecology 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 53-year-old female enrollee has requested a four-wheeled walker with a seat because she has multiple sclerosis. Findings:  The physician reviewer found that the patients medical condition is complicated, but pertinent to this discussion are her multiple sclerosis, cervical stenosis and compression fracture. Her neurosurgical evaluation describes her difficulty with gait and balance. The patient does have a mobility deficit that impairs her ability to perform mobility-related activities of daily living. The requested four-wheeled walker with a seat is medically reasonable to accommodate her mobility limitations and fall risk.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for risedronate sodium 35 mg. A study noted that bisphosphonates and denosumab reduce the risk of hip, nonvertebral, and vertebral fractures, while teriparatide reduces the risk of nonvertebral and vertebral fractures. In this case, the patient has osteoporosis of the bilateral hips. Given that the patient requires an osteoporosis agent that reduces risk of hip, nonvertebral, and vertebral fractures, the requested medication is medically indicated. Therefore, risedronate sodium 35 mg 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 internal medicine with sub-specialty certification 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested implantation of hormone pellets for treatment of the enrollees menopausal symptoms. Findings:  Three physician reviewers found that there are many U.S. Food and Drug Administration (FDA) approved treatments available for menopausal symptoms and for atrophic vaginitis.  Atrophic vaginitis can cause painful intercourse, which can impact libido, and there are several FDA-approved treatments, both topical and oral, for this condition.  In addition, decreased libido is multifactorial, and there is no evidence in the record of any evaluation or attempts at therapy other than hormone pellet implants.  If the goal is treatment with estrogen and testosterone, there is an available oral FDA-approved estrogen/testosterone combination that can be prescribed (Covaryx).  Udoff noted the use of testosterone is limited by the lack of approved and commercially available products for women. In addition, the doses of testosterone used and the mean serum concentrations of total testosterone achieved in women are supraphysiologic, resulting in important side effects such as acne and hirsutism. The long-term consequences of these relatively high serum testosterone concentrations are unknown.  In this case, the patient received a very high dose of testosterone, 200 mg, which is likely to cause supraphysiologic levels and potential side effects.  In sum, implantation of hormone pellets was not likely to have been of greater benefit than other treatment alternatives.   Final Result: 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: All three physician reviewers are board certified in obstetrics and gynecology 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for consultation with a urogynecologist at a tertiary care center. The records provided for review document that this patient has a diagnosis of pelvic pain and recurrent urinary tract infections (Dason, et al.). As noted in the medical literature, symptoms such as pelvic pain and frequent urinary tract infections are common urologic and gynecologic issues, which can be managed by urologists, gynecologists, and urogynecologists. This patients history and current presentation suggest that she is a candidate for evaluation and treatment with a urologist, gynecologist, or urogynecologist. A recent colonoscopy for recurrent rectal bleed demonstrated trace internal hemorrhoid in a healing phase. However, there is a lack of support for urogynecology services to be provided at a tertiary care center. Therefore, the requested consultation with a urogynecologist at a tertiary care center is not medically necessary for 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 urology 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 31-year-old female enrollee requested trametinib (Mekinist) for medical treatment of her acute myeloid leukemia.   Findings:  The physician reviewer found that based on review of the available records, this patient has highly refractory AML that has relapsed on conventional cytotoxic chemotherapy. With genomic profiling, the patients providers have identified a mutation which is present in about 10% of patients with AML (Pylayeva-Gupta, et al). The results from molecular profiling should help guide this patients next treatment regimen. Further, there is medical evidence supporting the safety and efficacy of trametinib in AML patients with NRAS mutations (Lauchle, et al; Lyubynska, et al). Consistent with these findings, the requested trametinib is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with primary osteoarthritis of the left knee. An x-ray of the left knee revealed mild tricompartmental osteoarthritis. The patient received a left knee corticosteroid injection. The patient reported left knee pain. Physical examination findings included tenderness to palpation over the left knee joint lines and facets. Prior treatment included left knee arthroscopy in 2015 and physical therapy. The patient has requested authorization and coverage for Hyaluronan (Euflexxa) injections (J7323) in the left knee. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Hyaluronan (Euflexxa) injections (J7323) in the left knee are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. Considering the foregoing, viscosupplementation can only be recommended for patients 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 patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Hyaluronan (Euflexxa) injections (J7323) in the left knee are medically necessary for the 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 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 five-year-old female enrollee has requested speech therapy, occupational therapy, physical therapy and applied behavioral analysis (ABA) for the treatment of the enrollees pervasive developmental disorder/autism. Findings:  The physician reviewer found that this patient has been diagnosed with autism based on evaluations by two child neurologists. The second child neurologist prescribed speech, physical and occupational therapy weekly programs. The patient was evaluated by qualified speech, physical and occupational therapists who recommended active therapeutic approaches. Applied behavioral analysis is not an experimental program, and the peer-reviewed literature has documented its effectiveness. The various therapies have been proposed as part of a comprehensive treatment plan for this patient and are medically appropriate for the treatment of autism. The requested therapy is medically indicated for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested inpatient hospital admission for treatment of his chest pain.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient presented with chest discomfort concerning for possible coronary ischemia but normal cardiovascular physical examination, normal electrocardiogram and normal cardiac troponin.  In this circumstance of a clinically stable patient with an initial negative evaluation, it would have been medically appropriate to manage the patient at an observational level of care as opposed to a hospital admission.  Based on the patients initial presentation, it would have been reasonable to anticipate the patients hospital length of stay would not exceed 24 hours.  The current medical evidence does not support the services at issue in this clinical setting.  All told, inpatient hospital admission was not medically indicated for the treatment of this patient.  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 internal medicine with sub-specialty certification in cardiovascular disease 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 53-year-old male enrollee has requested the ImmuKnow immune cell function assay for evaluation of his medical condition status post liver transplant.  Findings:  Two physician reviewers found that there is inadequate evidence from the medical literature that the ImmuKnow assay provides additional information which can be used in the clinical setting above and beyond measurement of therapeutic drug levels. A recent systematic review found that while it had reasonable accuracy for the prediction of opportunistic infections it provided heterogeneous results with respect to predicting organ rejection. Currently, this test is not considered the standard of care and was not likely to provide greater benefit in evaluating this patients medical condition than conventional alternatives.
Appeal type: Medical Necessity
Decision: Upheld

A 25-year-old female enrollee has requested spinal fusion surgery at L4-S1, extreme lateral interbody fusion for treatment of her lumbar pain.   Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested procedure. A review of the medical records demonstrates that the patient has chronic back pain which she attributes to a motor vehicle accident. Based on the documentation submitted for review including her neurological examinations, lumbar radiculopathy has not been established in this clinical setting as there is no evidence of defined symptoms matching a lumbar root distribution or motor, sensory, reflex findings (Tarulli and Raynor). Furthermore, the patient fails to meet Milliman Care Guidelines (MCG) and National Imaging Associates, Inc. (NIA) guideline criteria for surgical fusion which includes: spondylolisthesis with more than 4.5 mm instability, scoliosis, infection, tumor, fracture and stenosis with radiculopathy, neurogenic claudication, pseudarthrosis, rapidly progressive or severe neurologic deficits and imaging consistent with medical condition. In this patients case, she does not have any of the accepted criteria listed above. Thus, the requested procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Harvoni 90-400 mg, one tablet daily for eight weeks. 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 applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, treatment-naive, genotype 1 patients should be treated with Harvoni. Patients with viral loads less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on randomized clinical trial data showing a high cure rate with this regimen. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Additionally, the guidelines do not recommend NS5A resistance testing routinely prior to use of Harvoni.  For these reasons, Harvoni 90-400 mg, one tablet daily for eight weeks is medically necessary for the treatment of this patient. 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for MyRisk gene panel testing. Findings:  Two physician reviewers found that the patients family history is suggestive of a breast/ovarian cancer syndrome. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers. BRCA2 mutations can increase risk for breast, ovarian, gall bladder, bile duct, prostate, pancreatic, and gastric cancers. In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect. The Amsterdam criteria and the Bethesda consensus guidelines evaluate the occurrence of Lynch syndrome or hereditary nonpolyposis colorectal cancer (HNPCC) tumors in families. The most common extracolonic cancer in Lynch syndrome is endometrial cancer followed by ovarian, gastric, renal, small intestine, pancreas, hepatobiliary, and ureteral. In this clinical setting, the MyRisk gene panel testing provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Reviewers 2 and 3 determined that the testing 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 physician reviewers 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 57-year-old female enrollee requested authorization and coverage for testosterone cream. The health plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees biopsy proven lichen sclerosis.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: Experimental/Investigational
Decision: Upheld

A 21-year-old male has requested prescription medication Actos for the treatment of Lyme disease.  Findings:  Three physician reviewers found that the theory behind the request for Actos is to minimize the pro-inflammatory cytokines which are often elevated in individuals with biotoxin induced illness. A search of the literature does not reveal any studies in peer reviewed journals to support the above theory. There is also no evidence for the efficacy of cholestyramine and Actos in the treatment of Lyme disease. The literature submitted is opinion; it has not been published in a peer reviewed journal and is not supported by scientifically derived data. There are no double-blind, placebo-controlled trials to show the efficacy of these treatments. Further, there is little clinical evidence to support the diagnosis of late-stage Lyme disease.