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

A male enrollee requested hyaluronate injections for medical treatment of his knee pain.  Findings:  The physician reviewer found that the clinical documentation indicates that the patient continues to be significantly symptomatic and recalcitrant to medications and therapy.  Per the medical records, this patient has tricompartmental osteoarthritis.  The peer-reviewed literature supports the use of hyaluronate injections to assist pain relief and in an attempt to delay surgical intervention.  In this patients case, viscosupplementation would assist with pain control allowing a delay in further surgical treatment.  All told, the requested hyaluronate injections are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 51-year-old female with a history of a pelvic floor dysfunction and pudendal neuropathy resulting in painful muscle spasms. She has been receiving physical therapy utilizing pelvic floor therapy. In addition, biofeedback was used by the patients provider who has requested coverage for physical therapy and for biofeedback testing for diagnostic purposes. The Health Plan has denied reimbursement for physical therapy and biofeedback testing indicating the services were not medically necessary for treatment of the patients condition.It is the standard of practice that a patient with a particular symptom complex be availed of the proper medical consultations that will optimize the diagnosis and subsequent treatment. The submitted records do not include evidence the patient has had a complete diagnostic workup. A consultation with a gynecologist, neurologist, and physiatrist appear to be in order. In addition, the submitted information indicates the patient is taking Wellbutrin and Lexapro for treatment of clinical depression. As such, consultation with a psychiatrist may be appropriate (to rule out psycho-social factors that may be contributing to the patients symptom complex). In any event, based upon the information provided, the physical therapy services and biofeedback testing the patient received do not appear to have been of demonstrable benefit to her medical problems. As such, there is insufficient evidence the services at issue were medically warranted. Based upon the information set forth above, I have determined that 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Kerydin for treatment of his medical condition.    Findings:  The physician reviewer found that the patient is requesting Kerydin therapy for treatment of onychomycosis of the toenails. The nail dystrophy present is due to an infection with a dermatophyte or mold, but culture results are not included. There is no documentation of an intolerance or contraindication to use of oral terbinafine, including abnormal liver function tests. The patient has documented that immune system dysfunction makes treatment with oral terbinafine contraindicated. However, treatment with terbinafine has not been proven to be a contraindication for patients with immune system dysfunction. Thus, the requested treatment with Kerydin is not medically necessary. In addition, treatment with Kerydin is not expected to provide a more than minimal improvement in the appearance of the nails. Onychomycosis is a common condition, which can be difficult to eradicate as recurrences are frequent. Treatment with oral terbinafine usually lasts four months and has a noted success rate, albeit with frequent recurrences. Avulsion of the nail plate can also be performed and allow better access for treatment of the nail bed with a topical antifungal. Treatment with Kerydin is expected to take 48 months of therapy and has low efficacy. Given these findings, the requested Kerydin is not reconstructive in nature for treatment of this patients onychomycosis.  Final Result: The reviewer determined that the requested medication is not reconstructive in nature and 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: Medical Necessity
Decision: Overturned

A 55-year-old female enrollee has requested intravenous immune globulin therapy (IVIG) for treatment of her inflammatory sensory polyneuropathy.  Findings:  The physician reviewer found that the submitted clinical evidence demonstrates the patient has chronic inflammatory demyelinating polyneuropathy (CIDP) rather than idiopathic peripheral neuropathy. There are adequate studies documenting the efficacy of IVIG in CIDP such that its use in this patient is medically reasonable and appropriate. In fact, the patient has benefited from an ongoing trial of IVIG. Based upon the clinical evidence provided, the patient is an appropriate candidate for IVIG and is likely to continue to benefit from its use.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a procedure for treatment of the enrollee's keratoconus without scarring right eye. Findings: All three physician reviewers found that Intacs are intrastromal corneal ring segments that are implanted in the deep corneal stroma to modify the corneal curvature. This technology was first used to treat myopia and then adopted for the treatment of keratoconus. The purpose of Intacs is to reduce corneal steepening and thereby improving best corrected visual acuity. In 2004, Intacs was given a U.S. Food and Drug Administration (FDA) Humanitarian Device Exemption for use in keratoconus. Corneal cross-linking is a procedure used to slow or stop the progression of corneal thinning in keratoconus and post-refractive ectasia. The procedure was approved by the FDA in 2016. In this patients case, the implantation of the Intacs implants in the right eye for the treatment of patients keratoconus was indicated. However, the cross-linking procedure that was performed using the Holcomb C3-R system is not FDA approved. The standard FDA approved therapy for cross-linking is with the Avedro KXL system. In addition, there is a lack of peer-reviewed studies confirming the efficacy of the epithelial-on Holcomb C3-R system. Given these findings, the Intacs performed was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy, while the remaining codes were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that a portion of the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: All three physician reviewers are board certified in ophthalmology and are actively practicing. The reviewer 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: The patient has requested authorization and coverage for biofeedback therapy. Rao and Patcharatrakul note that dyssynergic defecation is common and affects up to one-half of patients with chronic constipation. The authors further note that biofeedback therapy is recommended as the first-line of treatment for dyssynergic defecation. Lee and colleagues report that patients with abnormal contractions of the puborectalis muscle seem to respond favorably to biofeedback treatment. Wald and colleagues found that biofeedback training protocols designed to correct dyssynergia and inadequate rectal propulsion were shown in three randomized controlled trials to significantly improve the ability to evacuate the rectum. In this case, the patient has symptoms and test results consistent with constipation due to dyssynergic defecation. She has failed multiple medical therapies, including advanced laxatives such as Linzess. In this clinical setting, the requested service is medically indicated. Therefore, biofeedback therapy is 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 14-year-old male enrollee has requested Increlex therapy for the treatment of the enrollees stated severe primary IGF-1 deficiency. Findings:  The physician reviewer found that the patient has delayed puberty and should achieve a normal adult height without intervention. IGF-1 deficiency is unlikely in this case. Growth hormone dependent IGF-1 and IGFBP-3 levels were normal. The low normal level of IGF-1 is often seen in delayed puberty prior to the adolescent growth spurt.  The requested therapy is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

A 22-year-old female enrollee has requested for surgical scar revision for treatment of her right buttock. Findings:  The physician reviewer found that the patient had an unaesthetic buttock depression and scar following a steroid injection. The plastic surgeons notes do not describe any functional limitations or discomfort related to the scar. The operative note indicates that scar excision and intermediate closure were performed. The records do not provide compelling evidence that the patients scar was painful or was causing significant functional problems. Moreover, the photographs show a simple scar depression that would not be expected to cause a functional problem.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested a home light box for ultraviolet B (UVB) therapy for treatment of her psoriasis.  Findings:  The physician reviewer found that available evidence indicates that narrow-band UVB phototherapy is safe to use in patients with a history of melanoma and it does not increase the risk of melanoma in these patients. Based upon the patients history of melanoma, the best options for treatment of this patient's psoriasis are topical therapy and UVB phototherapy. She has used limited topical therapy options and could try several others, including clobetasol in other vehicles such as spray or foam, other potent topical steroids with or without occlusion, Tazorac cream or gel, intralesional steroids, and Protopic ointment. The patient may want to consider the other available topical options as there is likelihood they will improve her condition. Concerning her request for home therapy, there is no indication the patient requires therapy in the home. She has requested home therapy because therapy at Health Plan facilities is not conducive to her work schedule. No medical need has been identified demonstrating the need for home therapy and appropriate therapy is available at Health Plan facilities.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 41-year-old male who carries the diagnosis of laryngopharyngeal reflux.  The patient is also a smoker. Trials of allergy medication, Prilosec (omeprazole) and Aciphex (rabeprazole) have not relieved his symptoms of throat irritation, excess clearing and the sensation of build up in the throat. A trial of Nexium (esomeprazole) therapy was prescribed and the enrollees provider submitted a request for authorization. The Health Plan denied the request citing a lack of medical necessity.Nexium is a non-formulary drug for this Health Plan. The Health Plans policy for non-formulary drugs clearly states that they may be approved if a patient has failed treatment with those drugs available on the formulary. The Health Plan offers omeprazole, rabeprazole and Protonix (pantoprazole) as formulary alternatives. This is a reasonable policy, and the patient did not undergo a trial of Protonix prior to his request for a trial of Nexium. As such, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old male enrollee requested authorization and coverage of a liver transplant for the treatment of hepatitis C, cirrhosis, and hepatocellular carcinoma.  The Health Plan denied the enrollees request indicating that the requested treatment 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 services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old female enrollee has requested an MRI study of the right knee for the evaluation of knee pain.  Findings:  The physician reviewer found that the only other option would be an arthroscopic evaluation of the knee, which is invasive. As such, an MRI study is the next appropriate step in the evaluation and treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for Oncotype DX testing. The enrollee is diagnosed with left breast cancer, estrogen and progesterone positive and HER-2 negative, after biopsy.  She underwent a bilateral mastectomy aan pathology confirmed the diagnosis and showed two positive lymph nodes.  She then had Oncotype DX testing for the purpose of determining a treatment plan.  Her Oncotype DX score was low and she is being treated with Tamoxifen.  The enrollee indicates the results from the Oncotype DX test demonstrated that she did not need chemotherapy and without it, she would have been subjected to treatment that would not have reduced her risk of recurrence. The medical literature recommends utilizing Oncotype DX to help guide therapy with chemotherapy, hormone therapy or both in node-negative patients. The patients final pathology report showed 2/5 lymph nodes were positive. Thus, the Oncotype DX is not indicated.Final Result: The reviewer determined that the service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in surgical oncology 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 48-year-old female enrollee has requested BRCA1 and BRCA2 testing for evaluation of her cancer risk. Findings:  Three physician reviewers found that the patient does not have a diagnosis of cancer. There are published guidelines that indicate when BRCA testing is clinically indicated. This patients family history as depicted in the single clinical note is not suggestive of a strong hereditary predisposition. As such, based on the information provided, the patient does not meet any of the accepted guidelines for BRCA1 and BRCA testing. The medical documentation provided does not support the utility of BRCA1 and BRCA2 testing in this setting. Thus, I have determined the requested genetic testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Linzess for treatment of the enrollees chronic idiopathic constipation.  Findings: The physician reviewer found that according to the American Gastroenterological Association (AGA), the first-line of therapy for patients with constipation should be an osmotic agent, and then a stimulant laxative should be tried. The guidelines also state that a newer agent such as Linzess should be considered when symptoms do not respond to such laxatives. In multicenter, randomized, blinded, placebo-controlled Phase III clinical trials, Linzess significantly increased weekly spontaneous bowel movements in patients with chronic constipation, but was associated with adverse effects. The prescribing information approved by the U.S. Food and Drug Administration (FDA) recommends the dose of 145 mcg per day rather than 290 mcg daily and cautions that the medication is contraindicated in patients with mechanical obstruction. This patient is noted to have a history of fecal impactions and has not reportedly been treated with an osmotic laxative. Given these findings, the requested Linzess 290 mcg is not supported as medically necessary for treatment of this patients chronic idiopathic constipation. 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee requested authorization and coverage of compounded hydrocodone for the treatment of chronic low back pain .  The Health Plan denied the enrollees request indicating that the requested treatment 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 for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee has requested for Rocephin for treatment of her condition.   Findings:  Three physician reviewers found that there is a lack of evidence in the medical literature that intravenous ceftriaxone will enhance the sensitivity or specificity of the Lyme urine antigen test, or that the test results would be useful in the diagnosis or treatment of Lyme disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intraosseous nerve ablation with the Intracept procedure at L4 and L5. The Intracept procedure is intended to be used in conjunction with radiofrequency generators for the ablation of basivertebral nerves of the L3 through S1 vertebrae for the relief of chronic low back pain. Criteria for treatment with Intracept include at least six months of symptoms that have not responded to at least six months of conservative care and is accompanied by either Type 1 or Type 2 Modic changes on an magnetic resonance imaging (MRI). Fischgrund and colleagues reported on a multicenter randomized control trial involving patients with refractory low back pain and Modic changes in the treated vertebral bodies. The authors found significantly greater improvement in patient reported outcomes with the Intracept procedure at three months compared to patients treated with placebo. In this case, the patient is being treated for chronic neck and low back pain. The treating provider has recommended the Intracept procedure. One randomized controlled trial demonstrated the potential for short-term benefit, but data are lacking to support long-term efficacy and safety beyond three months. Clinical conclusions on this procedures safety and efficacy require longer-term data prior to determine whether the procedure is equivalent or superior to standard available therapies. All told, the requested intraosseous nerve ablation with the Intracept procedure at L4 and L5 is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested intraosseous nerve ablation with the Intracept procedure at L4 and L5 is not 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 services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in ** 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.