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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) Nurtec ODT 75 mg or (2) Ubrelvy 50 mg tablet. The American Headache Society (AHS) notes that in individual pharmacological therapies for acute migraine treatment, non-steroidal anti-inflammatory drugs (NSAIDs) and triptans are effective for the treatment of acute migraine attacks. The U.S. Food and Drug Administration (FDA) describes Nurtec ODT as a calcitonin gene-related peptide (CGRP) receptor antagonist indicated for the acute treatment of migraine with or without aura in adults. In a randomized, double-blind, placebo-controlled trial, Croop and colleagues reported that that the percentage of patients achieving headache pain freedom two hours after a single dose was statistically significantly greater in patients who received Nurtec ODT compared to those who received placebo. The authors further reported that there were no serious adverse events or safety concerns. While the AHS guidelines have not yet been updated to include recommendations on CGRP therapies, Pringsheim and colleagues note that when the initial treatment for an acute migraine does not provide meaningful and sustained benefits, a treatment from a different medication class is typically chosen. In this case, the patient has a history of migraines that have not responded to multiple oral abortive therapies including triptans such as rizatriptan and sumatriptan. Given that Nurtec ODT is an alternative treatment and a different medication class approved by the FDA for the treatment of acute migraines in adults, the requested medication is medically indicated. Therefore, (1) Nurtec ODT 75 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested advanced lipoprotein testing for evaluation of his medical condition. Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this patients case.  Guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations.  These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein, high-density lipoprotein subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.   For example, randomized trials testing treatment with therapy available to reduce homocysteine levels have not shown significant outcomes benefits.   Likewise, even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results.  Thus, the superior efficacy of advanced lipoprotein testing has not been established. Final Result: Three 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Medical Necessity
Decision: Overturned

A 43-year-old male has requested  past and future coverage of Oxycontin for treatment of his fibrous dysplasia.  Findings:  The physician reviewer found that based on review of the available records, the patient has been stable on Oxycontin for several years on a consistent basis with no diversion issues. The provider reports that the patients pain has been well controlled over the past several years with Oxycontin. In addition, a change to another medication may be difficult to titrate and may not manage the patients chronic pain as well as the Oxycontin. Chronic narcotics can be difficult to titrate and the cross-reactivity may provide adequate pain relief, but transition can be quite difficult. Given the adequacy of pain control provided to this patient with Oxycontin for his painful conditions, and the lack of adverse events or improper use, the requested medication is supported as medically necessary in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for her breast examination. Findings:  Three physician reviewers found that 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 the dense breast. In this particular patient, she was noted to have heterogeneously dense breasts. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. The medical literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate. This technology has the potential to change conventional mammographic screening and diagnostic imaging with improvements in cancer detection, decreased call backs, and fewer false positive biopsies. For these reasons,  breast tomosynthesis was likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the service at issue was likely more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  One reviewer is board certified in radiology and is actively practicing. Two reviewers are board certified in radiology with sub-specialty certification in diagnostic radiology 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: Medical Necessity
Decision: Overturned

A 58-year-old female enrollee has requested for inpatient hospital services for treatment of her wound infection.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  Given the patients underlying diabetes mellitus which is a risk factor for both poor wound healing as well as postoperative infections, as well as the failed prior treatment with intravenous antibiotics, it was necessary to maintain the patient on postoperative antibiotics for at least 24 hours after surgery prior to conversion to an oral regimen. Although the patient had a normal white blood cell count and was afebrile, indicating the absence of ongoing systemic signs of infections, intravenous antibiotics were required given the risk factors for further infection.  All told, inpatient hospital services provided from the specified timeframe were medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

 Nature of Statutory Criteria/Case Summary:  An enrollee has requested chest surgery (repair of pectus carinatum) for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity for the surgery at issue. In this case, the patient presented with pectus excavatum, a congenital chest/breast deformity. This condition was treated with chest reconstruction using pre-pectoral implants. The patient has a well-recognized congenital deformity that requires complex reconstruction.  Reconstructive surgery is generally done to improve function but may also be done to approximate a more normal appearance, as in this case. Therefore, the chest surgery (repair of pectus carinatum) was medically necessary and is the standard of care for a congenital defect. All told, chest surgery (repair of pectus carinatum) was medically necessary and reconstructive in nature for treatment of the patients medical condition.   Final Result: The reviewer determined that the service at issue were medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for occipital nerve blocks. Findings:  The physician reviewer found that At issue is whether the requested occipital nerve blocks are medically necessary for treatment of this patient. Barmherzig and colleagues evaluated the current evidence and recommendations for the diagnosis and management of occipital neuralgia. The authors concluded that, Anesthetic block of the greater and/or lesser occipital nerves are often used both diagnostically and therapeutically. However, evidence is limited as most studies are noncontrolled. Occipital nerve blocks with or without corticosteroids yield transient benefit in most, with 15-36% sustaining extended relief for several months. Chowdhury and colleagues evaluated 72 different studies examining the role of the greater occipital nerve block for patients with headache disorders. The authors found that, the greater occipital nerve-block can be an effective acute and short-term preventive treatment option for migraine patients. Its long-term preventive efficacy however needs to be assessed by further randomized controlled trials. In this case, the patient has been diagnosed with chronic migraines and occipital neuralgia, which has been refractory to medication management with multiple classes of agents. However, the studies supporting the use of the occipital blocks have been too small or poorly designed to draw conclusions about their effectiveness for treating occipital neuralgia. Overall, there is a lack of studies evaluating the safety and efficacy of occipital nerve blocks to support their use in the management of this patients chronic migraines and/or occipital neuralgia. Therefore, the requested occipital nerve blocks are 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 anesthesiology with subspecialty certification in pain 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

A 35-year-old female enrollee has requested laparoscopic lysis of adhesions and evaluation for possible endometriosis for the treatment of her medical condition. Findings:  The physician reviewer found that while a laparoscopy for the purpose of assessing this patients infertility is medically appropriate in this setting, at issue is whether the proposed procedure is medically necessary for treatment of a medical condition other than infertility. Review of the submitted evidence does not demonstrate sufficient symptoms or findings to justify a laparoscopy for any other indication.  References on evaluation of chronic pelvic pain and endometriosis generally discuss the presence of symptoms over time as well as other possible findings. As noted in the treatment notes from the patients reproductive endocrinologist, the patient does not have pelvic pain and had an unremarkable exam and ultrasound. Per American College of Obstetrics and Gynecology (ACOG) guidelines, chronic pelvic pain is generally defined as lasting for more than six months. Regarding endometriosis, again per ACOG guidelines, dysmenorrhea, chronic pelvic pain, dyspareunia, uterosacral ligament nodularity, and adnexal mass (either symptomatic or asymptomatic) are among the most well-recognized manifestations. It is true that endometriosis can be asymptomatic or cause subtle symptoms, but under those circumstances, the diagnosis is not consequential, except perhaps for infertility. The patients other co-existing issues (abnormal periods, ovulatory disorder) are not relevant to the decision to perform a laparoscopy and are not caused by endometriosis. Management of these issues would not be influenced by laparoscopic findings. Thus, based on the evidence provided, but for the patients problems conceiving, there is no indication for a laparoscopy in this case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Rituxan (rituximab 1000 mg every two weeks). Sharp and colleagues explain that connective tissue disease-associated interstitial lung disease often fails to respond to conventional immunomodulatory agents. In examining the results of 24 patients with interstitial lung disease patients treated with rituximab after failing to improve with standard therapy, the authors reported that lung imaging remained stable or improved for 11 patients, while worsening was observed in nine patients. The authors found that decline in forced vital capacity (FVC) improved following rituximab treatment, while diffusion capacity of carbon monoxide was stable. The authors concluded that rituximab is a therapeutic option in treatment-refractory connective tissue disease-associated interstitial lung disease. Similarly, in evaluating ten patients with connective tissue disease-associated interstitial lung disease, Fitzgerald and colleagues noted a statistically significant improvement following rituximab therapy in pulmonary function, with a mean increase of 19% in diffusing capacity of the lungs for carbon monoxide (DLCO), and a mean increase of 13% in FVC. The authors concluded that treatment with rituximab resulted in an objective, measurable improvement in pulmonary function and/or radiological severity in patients with connective tissue disease-associated interstitial lung disease, and that the improvements in pulmonary function were statistically significant despite the small number of study participants. In a systematic review, Bellan and colleagues reported that overall agreement existed concerning the effectiveness of rituximab in the stabilization of lung disease, with some studies reporting an improvement of functional parameters from baseline. Given that current medical literature supports the use of the requested medication in this patients clinical setting of undifferentiated connective tissue disease-associated interstitial lung disease, the requested medication is medically indicated. Therefore, Rituxan (rituximab 1000 mg every two weeks) 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: Medical Necessity
Decision: Overturned

A 28-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested surgery is not medically necessary for treatment of the enrollees obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary depending upon the results of a psychological evaluation.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 67-year-old male with stage IV metastatic colorectal carcinoma. His disease is chemorefractory. His provider has recommended Sutent, citing the patients inability to tolerate traditional agents. The Health Plan has determined that Sutent is not medically necessary in this clinical setting.The Health Plans denial should be upheld. There is no compelling data supporting the use of Sutent in this setting. No significant trials of the proposed usage have been performed. There is inadequate data demonstrating small molecule tyrosine kinase inhibitors (TKIs) can be substituted for Ab (bevacizumab). Given the data available at this time, there is inadequate evidence the proposed therapy will result in any clinical benefit. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 gene testing for evaluation of the enrollees lung cancer. Findings:  Two physician reviewers found that the Guardant360 gene testing provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The National Comprehensive Cancer Network (NCCN) guidelines indicate that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. The NCCN guidelines strongly endorse broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with lung cancer. Multiplexed genotype testing allows an entire panel of genotypes of interest to be queried at a single time from a single tissue sample instead of doing the tests sequentially one by one. This is the most tissue-efficient approach, particularly when dealing with small tumor samples. In addition, multiplexed genotyping is the most time-efficient process for screening patients and thus to facilitate prompt treatment or protocol inclusion. For the treatment of patients with lung cancer broad molecular profiling, such as with Guardant360 testing, is considered a standard of care. For the reasons provided, the Guardant360 gene testing provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers 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: 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested abdominoplasty for treatment of her medical condition.   Findings:  The physician reviewer found that there is a lack of support for the requested services in this clinical setting.  The records document abdominal diastasis recti in the setting of an umbilical hernia.  The repair of diastasis recti is not generally considered to be a functional treatment but can be an integral part to cosmetic procedures, namely abdominoplasty.  There is insufficient documentation from the treating providers to support a functional deficit directly related to the rectus diastasis.  Although there is some indication that muscle plication may affect intractable lower back pain, the current medical evidence suggests that nonoperative therapy and significant work-up for other reasons of the pain should be evaluated prior to abdominoplasty with muscle plication.  In this patients case, records from the treating providers do not document a functional deficit directly related to the diastasis recti.  All told, the requested abdominoplasty is not medically indicated for the 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 plastic 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.