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

A 34-year-old female enrollee has requested magnetic resonance imaging and Norco 10/325 for treatment of her chronic neck pain.  Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested diagnostic procedure and medication.  The indications for an MRI of the brain include recent trauma to rule out subdural hematoma or subarachnoid bleed, acute neurologic findings, recent cerebrovascular accident or transient ischemic attack.  These indications are not documented in the submitted records.  The current medical evidence does not support the use of Norco chronically for low back pain or cervicalgia.  Longer acting opiates are thought to be more suitable for chronic administration.  All told, the requested MRI and Norco 10/325 are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Octagam infusions. This patient presents with complaints of ataxia, dizziness, weakness, dysarthria, and dysphagia. Her provider has recommended treatment with Octagam intravenous immunoglobulin (IVIG). Eftimov and colleagues noted that, Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) causes progressive or relapsing weakness and numbness of the limbs, developing over at least two months. IVIG is a U.S. Food and Drug Administration (FDA) approved medication that has been demonstrated to be safe for the management of several neurological diseases. Although this patient is experiencing severe symptoms, there is a lack of documentation in the records provided for review to support an indication for IVIG Octagam infusions. Therefore, the requested Octagam infusions are 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 with subspecialty certification in vascular 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 reimbursement for gene testing, DecisionDx-Melanoma Gene Assay. Findings:  Three physician reviewers found that this patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines state while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. The results of the services at issue were not likely to have altered treatment and surveillance recommendations. Therefore, gene testing, DecisionDx-Melanoma Gene Assay was not likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old female enrollee requested authorization and coverage of the medication Sarafem.  The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees premenstrual dysphoric disorder.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old female enrollee has requested for right ankle replacement surgery for treatment of her arthritic ankle. Findings:  Two physician reviewers found that the FDA approved the Agility total ankle prosthesis in 2002.  The intention of this procedure is to give the patient limited mobility by reducing pain, restoring alignment and replacing flexion and extension movement of the ankle joint.  Early studies were not encouraging, but intermediate term results were somewhat better.  Considering the evidence of this particular patients clinical condition and information currently available in the literature, total ankle replacement may be a better procedure for her.
Appeal type: Experimental/Investigational
Decision: Overturned

A 57-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder (MDD), severe. Findings:  Two physician reviewers found that scientific evidence has established TMS to be a safe and efficacious treatment for major depressive disorder (Janicak, et al). For this reason, TMS is currently being widely utilized in clinical practice at leading academic medical centers. This patients history of treatment for MDD shows that she has failed to receive adequate relief of symptoms from adequate trials of psychopharmacologic agents. The provider indicates that despite these treatments as well as cognitive behavioral therapy (CBT), the patient continued to experience significant levels of depression. Additionally, it is worth noting that TMS has been reported to be free of complications associated with anesthesia, cardiac risks, and memory disturbances as reported with electroconvulsive therapy (ECT) in the treatment of depression and has a mild side effect profile. All told, the use of TMS for the treatment of MDD was scientifically established and in widespread use prior to this patients start of TMS therapy. Therefore, the therapy at issue was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture treatment. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  The records indicate that the patient has a history of chronic pain which flared during pregnancy as well as nausea. The patient reported throbbing in her hands, forearms, elbows, shoulder and upper back.  Per the records, Tylenol was ineffective.  There is sufficient support for the requested acupuncture treatment in this clinical setting.  Per the medical literature, an acupuncture trial for the patients musculoskeletal condition and nausea is appropriate. All told, the requested acupuncture treatment is medically indicated for the treatment of this patient.  Final Result: The reviewers 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: Physician reviewer number one is board certified in oriental 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for four chiropractic services a month. In a systematic review and meta-analysis of 47 randomized controlled trials on the benefits and harms of spinal manipulative therapy (SMT) for the treatment of chronic low back pain, Rubinstein and colleagues reported that SMT produced similar effects to recommended therapies for chronic low back pain, and appeared better than non-recommended interventions for the improvement in function in the short term. Coulter and colleagues concluded that there is moderate quality evidence that both manipulation and mobilization appeared safe and were likely to reduce pain and improve function for patients with chronic low back pain, with manipulation appearing to produce a larger effect than mobilization. In this case, the patient has chronic low back pain. She reports functionality and relief with four chiropractic sessions a month. Given that the patient is unable to function without the requested services and that her provider recommends continued chiropractic services, the requested services are medically indicated. Therefore, four chiropractic services a month 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 chiropractic 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 31-year-old female enrollee has requested abdominoplasty and brachioplasty for the treatment of her excess skin. Findings:  The physician reviewer found that the submitted clinical evidence does not establish that the proposed procedures are reconstructive in nature. This patient has some hanging skin but no abnormal structure caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. The patients condition is normal in that the excess skin is not visibly affected by disease or infection and the amount of excess skin is not so great as to be considered abnormal. Thus, the proposed procedures do not meet the definition of reconstructive surgery as defined by California Health and Safety Code Section 1367.63. Furthermore, with regard to general concepts of medical necessity, there is no photographic documentation of arm-related rashes, skin ulcerations, intertrigo or loss of range of motion. The abdominal photographs do document some hyperpigmentation, but do not document skin ulcerations, or loss of a functioning body part due to the excess skin. There is a lack of dermatology or primary care physician (PCP) notes which diagnose and treat skin related conditions with failure of conservative treatments over a period of months. All told, there is a lack of evidence of any physiologic dysfunction Therefore, the medical necessity of the proposed abdominoplasty and brachioplasty has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the magnetic resonance imaging (MRI) of the bone marrow performed for evaluation of his monoclonal gammopathy of undetermined significance (MGUS).  Findings:  Three reviewers found that the whole body MRI is indicated for patients who are being evaluated for smoldering myeloma versus multiple myeloma. MRI can detect diffuse and focal bone marrow lesions in patients with multiple myeloma without osteopenia or focal osteolytic lesions on standard metastatic bone surveys and bone surveys can detect lesions not found on MRI of the axial skeleton. In addition, MRI is supported by the National Comprehensive Cancer Network (NCCN) guidelines. As such, MRI of the bone marrow performed on was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: Three reviewers are board certified in internal medicine with sub-specialty certification in hematology and 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Esbriet for treatment of the enrollees idiopathic pulmonary fibrosis.  Findings:  Two physician reviewers found that the medical literature supports the efficacy of Esbriet in this clinical setting. This patient has moderate to severe reduction in air volume with a forced vital capacity (FVC) measured at 55% and total lung capacity (TLC) of 51%. These outcomes are indications for treatment of IPF. The provider noted that this patient is intolerant to Ofev due to diarrhea, a common side effect reported in 62% of patients (versus 18% with placebo) in reported trials. After stopping Ofev, this patient should be allowed to begin Esbriet given her significant reduction in lung function which has continued to decline over the past year. Given this patients side effects with Ofev the requested medication Esbriet is an effective treatment option for this patient. The medical literature suggest that there are very few proven alternatives for treatment of this patients medical condition.  Final Result: The reviewers determined that the requested medication 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: Reviewer 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in pulmonary disease 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 testing. Findings:  Two of the three physician reviewers found non-small cell lung cancer should be tested for specific mutations, such as EGFR, ALK, ROS-1, as well as PDL-1. Each of these has a specific therapeutic implication. This testing should preferentially be done on a tissue sample, but can be done on liquid assay. Patients with an EGFR mutation who are treated with Tarceva and experience progression should be tested for a secondary mutation, T790M, as this also has a therapeutic implication. If these molecular profiles cannot be done on tissue, then Guardant360 assay may be indicated. However, in this patients case, it appears that there was appropriate testing on the cytology specimens. Therefore, further broad testing with Guardant360 testing was not likely to have been clinically beneficial. In sum, Guardant360 testing was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for IVIg Gammagard liquid 10% (37 grams every 2 weeks). Hovaguimian and Gibbons note that management of small-fiber neuropathy depends on the underlying etiology with concurrent treatment of associated neuropathic pain. Finnerup and colleagues report that inadequate response to drug treatments constitutes a substantial unmet need in patients with neuropathic pain. Liu and colleagues report evidence suggesting that intravenous immunoglobulin (IVIg) is safe and effective as a first-line treatment for patients with small-fiber-targeting autoimmune diseases akin to Guillain-Barre and chronic inflammatory demyelinating polyneuropathy. The authors note in a study of 55 patients with small-fiber polyneuropathy that overall, 74% of patients rated themselves as improved and their neurologists labeled 77% as IVIg responders. The authors further noted that 16% of the participants entered remissions that were sustained after IVIg withdrawal. In a review of various studies regarding immunotherapy for distal small-fiber polyneuropathy, Oaklander reports, These reports provide a rationale for treating carefully selected patients with immunomodulatory therapies. Candidates should have symptoms consistent with small-fiber polyneuropathy, objective confirmation of diagnosis, exclusion of other causes, failure to improve with symptom management, and, ideally, serologic markers of immunity/inflammation. In this case, the patient has small-fiber polyneuropathy. A providers letter reported laboratory evidence of autoimmunity. Current medical literature supports the finding that  patients with autoimmune small fiber neuropathy may improve clinically with IVIg. Therefore, IVIg Gammagard Liquid 10% (37 grams every 2 weeks) is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested IVIg Gammagard liquid 10% (37 grams every 2 weeks) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in neurology and are actively practicing. Physician reviewer 3 is board certified in neurology with sub-specialty certification in vascular neurology and is 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 authorization and coverage for prescription modafinil for treatment of the enrollees excessive daytime sleepiness. Findings: The physician reviewer found that Modafinil is U.S. Food and Drug Administration (FDA) approved for patients with excessive sleepiness associated with OSA, narcolepsy or shift work disorder. The documentation submitted for review does not support the patient has any of these diagnoses. According to the American Academy of Sleep Medicine, the diagnostic criteria for shift work disorder requires: a report of insomnia and/or excessive sleepiness, accompanied by a reduction of total sleep time, which is associated with a recurring work schedule that overlaps with the usual time for sleep; symptoms have been present and associated with the shift work schedule for at least three months; symptoms cause clinically significant distress or impairment in mental, physical, social, occupational, education, or other important areas of functioning; sleep log and actigraphy monitoring (whenever possible and preferably with concurrent measurement of light exposure) for at least 14 days (work and free days) demonstrate a disturbed sleep and wake pattern; and sleep and/or wake disturbance are not better explained by another current sleep disorder, medical or neurologic disorder, mental disorder, medication use, poor sleep hygiene, or substance use disorder. In this case, the patients work schedule does not lead to a reduction in total sleep time as she is noted to get 8.0 to 8.5 hours of sleep during the week. Her work schedule does not readily overlap with the usual time for sleep. It is also not clear that the excessive daytime sleepiness is not due to other causes such as poor sleep hygiene, particularly on the weekends. There is also no documentation of a disturbed sleep pattern via sleep logs to help evaluate the patients condition as required by current diagnostic criteria. Although the provider states that the patient may have a circadian rhythm disorder, current practice guidelines do not endorse the use of pharmacotherapy in such conditions. In sum, the records provided for review fail to establish a diagnosis of shift work disorder based on current diagnostic criteria. 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 with sub-specialty certification in sleep 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:  An enrollee has requested the Bioness L-300 Foot Drop System for treatment of his medical condition.   Findings:  The physician reviewer found that the Bioness L-300 Foot Drop System is not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient has not had a lengthy trial of a well fitted ankle-foot orthosis (AFO), custom made if necessary to improve compliance and comfort. An AFO is the first-line treatment for his condition and he has not exhausted the possibility of benefit from this type of device. In addition, researchers assessed the effects of a neuroprosthesis (NESS L300) designed to ameliorate foot drop on gait symmetry and rhythmicity during walking. They found that use of the NESS L300 makes gait more symmetric, reduces stride variability, and improves walking speed. In this case, these benefits were not seen in the patients brief trial. The Bioness device was objectively inferior to the AFO. All told, the requested services are not indicated 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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.